Noninvasive Ambulatory Electrocardiographic Markers from Patients with COVID-19 Pneumonia: A Report of Three Cases.

Coronavirus disease 2019 (COVID-19) has affected medical practice. More than 7,000,000 patients died worldwide after being infected with COVID-19; however, no specific laboratory markers have yet been established to predict death related to this disease. In contrast, electrocardiographic changes due to COVID-19 include QT prolongation and ST-T changes; however, there have not been studies on the ambulatory electrocardiographic markers of COVID-19. We encountered three patients diagnosed as having COVID-19 who did not have a prior history of significant structural heart diseases. All patients had abnormalities in ambulatory echocardiogram parameters detected by high-resolution 24 h electrocardiogram monitoring: positive late potentials (LPs) and T-wave alternans (TWA), abnormal heart rate variability (HRV), and heart rate turbulence (HRT). Case 1 involved a 78-year-old woman with a history of chronic kidney disease, Case 2 involved a 76-year-old man with hypertension and diabetes, and Case 3 involved a 67-year-old man with renal cancer, lung cancer, and diabetes. None of them had a prior history of significant structural heart disease. Although no significant consistent increases in clinical markers were observed, all three patients died, mainly because of respiratory failure with mild heart failure. The LP, TWA, HRV, and HRT were positive in all three cases with no significant structural cardiac disease at the initial phase of admission. The further accumulation of data regarding ambulatory electrocardiographic markers in patients with COVID-19 is needed. Depending on the accumulation of data, the LP, TWA, HRV, and HRT could be identified as potential risk factors for COVID-19 pneumonia in the early phase of admission.

Specificity of tuberculin skin test improved by BCG immunization schedule change in Japan.

INTRODUCTION: Tuberculin skin test (TST) has been used to diagnose tuberculosis (TB) and latent tuberculosis infection (LTBI). However, in Bacillus Calmette-Guérin (BCG) vaccinated patients, TST tends to produce false-positive results. According to the previous vaccination schedule, Japanese people were mandated to receive up to three doses of BCG-vaccine. The vaccination schedule was changed in 2003 and as per the new schedule, only infants are administered a dose of BCG vaccine. Our hypothesis is that this change can lead to a reduction in the cross-reaction to TST. METHODS: We evaluated the TST results obtained from 1097 recruits from six defense camps and 667 recruits from an air base. These TST data were divided into two groups according to the date of birth: a new group and an old group according to the BCG immunization schedule. We then analyzed positive and negative reaction of TST and erythema sizes. RESULTS: We confirmed that the change in BCG-vaccination schedule significantly decreased TST false-positive reaction (Pmeta = 1.4 × 10-18; risk ratio = 0.83; 95% confidence interval: 0.80-0.87) and erythema size (Pmeta = 1.1 × 10-4; mean difference = 6.6 mm; 95% confidence interval: 3.2 mm-9.9 mm). CONCLUSIONS: We showed the reduction in BCG cross-reaction to TST, in the new BCG vaccination schedule group, compared to the old group, we also have extracted information on the improvement in the specificity of TST for LTBI and TB diagnosis, which resulted from BCG schedule change.

Anorexia Nervosa With Intermittent Fever Due to Diet-Induced Thermogenesis: A Case Report.

Diet-induced thermogenesis, influenced primarily by protein intake, generates energy from food. Herein, we present the case of anorexia nervosa in a 30-year-old woman, who developed intermittent fever while transitioning from continuous to intermittent tube feeding, with an increase in protein intake. Extensive investigations ruled out infection- or drug-related causes, indicating that intermittent fever resulted from diet-induced thermogenesis due to high protein administration. Recognizing the potential for diet-induced thermogenesis in cases of fever during tube feeding is crucial to avoid unnecessary antibiotic use and prevent the discontinuation of essential medications.

Usefulness of the Simple Coma Scale, a Simplified Version of the Glasgow Coma Scale.

The Glasgow Coma Scale (GCS) is the most commonly used consciousness rating scale worldwide. Although it is a sensitive and accurate way of assessing a patient's level of consciousness, it is time-consuming and requires training. We designed the Simple Coma Scale (SCS) as a simplified version of the GCS. In this study, we examined whether the SCS could predict favorable neurogenic outcomes at discharge, survival, and GCS scores in patients with traumatic brain injury (TBI). We analyzed the data of 1,230 patients registered in the Japan Neurotrauma Data Bank (Project 2015) between April 2015 and March 2017. In the SCS, eye, verbal, and motor scores are given based on a 3-point scoring system, with similar wording ("Normal," "Something Wrong," and "None") used for all scores. The SCS is based on a 7-point scale. The Glasgow Outcome Scale was used to assess the outcomes. For the receiver operating characteristic (ROC) curves with the objective variable of good prognosis at discharge in the SCS and GCS, the area under the curve (AUC) for the SCS was 0.740 (95% confidence interval [CI]: 0.711-0.769), and that of the GCS was 0.757 (95% CI: 0.729-0.786). For ROC curves with survival as the objective variable, the AUC of the SCS was 0.751 (95% CI: 0.724-0.778), and that of the GCS was 0.764 (95% CI: 0.737-0.791). The SCS, similar to the GCS, may predict good prognosis and survival at discharge. Further analyses will continue to examine the usefulness and practicality of the SCS.

Effectiveness of Body Armor Against Shock Waves: Preventing Blast Injury in a Confined Space.

Introduction Blast injuries in modern society often occur owing to terrorist attacks in confined spaces, particularly in urban settings, indoors, and in vehicles, leading to significant damage. Therefore, it is important to focus on blast injuries in confined spaces rather than in conventional open-field experiments. Materials and methods We used an air-driven shock wave generator (blast tube) established indoors in 2017 and conducted basic research to potentially save the lives of patients with blast injuries. Under general anesthesia, pigs were divided into with body armor (BA) and without BA groups. The pigs were fixed in the measurement chamber with their dorsal chest directly exposed to the shock wave. The driving pressure was set at 3.0 MPa to achieve a mortality rate of approximately 50%. A generated shock wave was directly applied to the pigs. Comparisons were made between the groups with respect to cardiac arrest and survival, as well as apnea, bradycardia, and hypotension, which are the triad of blast lung. Autopsies were performed to confirm the extent of the organ damage. Statistical analysis was performed using Fisher's exact test, and statistical significance was set at p<0.05. The animal experimentation was conducted according to the protocol reviewed and approved by the Animal Ethics Committee of the National Defense Medical College Hospital (approval number 19041). Results Eight pigs were assigned to the BA group and seven pigs to the non-BA group. In the non-BA group, apnea was observed in four of seven cases, three of which resulted in death. None of the eight pigs in the BA group had respiratory arrest; notably, all survived. Hypotension was observed in some pigs in each group; however, there were no cases of bradycardia in either group. Statistical analysis showed that wearing BA significantly reduced the occurrence of respiratory and cardiac arrest (p=0.026) but not survival (p=0.077). No significant differences were found in other vital signs. Conclusions Wearing BA with adequate neck and chest protection reduced mortality and it was effective to reduce cardiac and respiratory arrest against shock wave exposure. Mortality from shock wave injury appears to be associated with respiratory arrest, and the avoidance of respiratory arrest may lead to survival.

Shock wave damage from the ventral side in primary blast injury: An experimental study in pigs.

AIM/PURPOSE: This study aimed to apply a shock wave from the ventral side of a pig and examine its effect to use the results for new body armor production for humans. METHODS: Seven male hybrid pigs were used. Each pig was placed under general anesthesia on the experimental table in a blast tube in the left lateral position to expose the front chest area, and shock waves generated by compressed air at 3.0 MPa were applied. We examined changes in vital signs and arterial blood gas in the hyper-acute phase and computed tomography (CT) images, and autopsies were performed for organ damage after 3 h of observation. Pathological examination was performed for lung damage, which is considered a characteristic of shock wave injury. RESULTS: All seven pigs survived. Respiratory arrest occurred in two pigs; however, spontaneous breathing resumed promptly afterward. Hypotension occurred at a frequency of 4. No bradycardia or cardiac arrest was observed in any pig. In the arterial blood gas analysis before and immediately after shock wave exposure and 1 h later, PaO2 decreased immediately but tended to improve thereafter. CT revealed pulmonary contusions and multiple bulla-like lesions on the surface of the lungs. An autopsy showed lung injury in all pigs, particularly in five cases with bulla-like lesions of various sizes on the lung surface across all lobes. Pathological findings showed visceral pleural detachment with elastic fibers from the lung parenchyma, and the cavity lesion on the lung surface comprised bullae. The degree of intra-abdominal hemorrhage varied; however, all but one case showed splenic injury. CONCLUSION: None of the pigs exposed to shock waves from the ventral side died; however, most showed multiple bullae on the lung surface with lung contusion and splenic injury, which may have been greater than those exposed from the dorsal side. This may be due to the direct impact of the shock wave proceeding from the epigastrium and subcostal region, which are not protected by the skeletal structure of the thorax. These characteristics should be considered when producing new body armor for humans to protect the body from shock waves.

Cardiac tamponade due to eosinophilia treated with intravenous corticosteroid: A case report.

RATIONALE: Cardiac tamponade, a condition in which the heart is compressed by pericardial fluid retention, is easy to diagnose; however, identifying the cause may be challenging since it can be caused by a variety of conditions, including trauma and pericardial disease. PATIENT CONCERNS: A 22-year-old man was admitted to the intensive care unit with respiratory failure. He had previously received allogeneic hematopoietic stem cell transplantation for acute myeloid leukemia and developed chronic graft-versus-host disease (cGvHD) that was treated with a corticosteroid. At this time, he developed bilateral femur head necrosis and underwent surgery after discontinuation of the corticosteroid but developed respiratory failure postoperatively. The initial diagnosis was cardiac failure, which temporarily improved with treatment; however, eosinophilia and pericardial effusions became prominent. DIAGNOSES: Pericardial effusion gradually progressed, resulting in cardiac tamponade. INTERVENTIONS: Pericardiocentesis was performed. Eosinophilia could be the cause of cardiac tamponade; thus, corticosteroid was administered. OUTCOMES: Pericardial effusion improved remarkably after corticosteroid administration. The corticosteroid dose was gradually tapered, and the patient was discharged. LESSONS: This case presented with cardiac tamponade associated with eosinophilia, probably owing to graft-versus-host disease. This is an unusual condition associated with a history of hematologic neoplasms; although evaluation is challenging, appropriate assessment could help save the patient's life.

A life-threatening case of pheochromocytoma crisis with hemodynamic instability.

Background: Pheochromocytoma crisis (PCC) is a fatal disease characterized by hyper and/or hypotension, hyperthermia, and encephalopathy, and its diagnosis and treatment are challenging. Case presentation: A 50-year-old woman presented with hypertension, and computed tomography showed an adrenal tumor. Fever, shock, and impaired consciousness were observed, and PCC was diagnosed clinically. Systolic blood pressure fluctuated from 40-220 mmHg within a few minutes, and circulatory agonists were adjusted accordingly. The blood pressure changes gradually stabilized with α-blockade. Surgery was performed on hospital day 26, and the pathological diagnosis was consistent with a pheochromocytoma. She was discharged on hospital day 37. Conclusion: Computed tomography may facilitate early diagnosis in the acute phase of PCC in case of limited patient medical information and insufficient time to wait for a definitive diagnosis using traditional hormone tests. The shock requires pharmacological therapy to maintain circulation, and paradoxically, the administration of α-blockade can be lifesaving.

A Case of Fulminant Fusobacterium necrophorum Bacteremia Secondary to Non-severe COVID-19.

The Omicron variant of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is more infectious than the previous variants but less severe; more patients are being followed up without hospitalization. Identification of patients with severe disease symptoms as early as possible and prompt initiation of treatment are crucial. A case of a 19-year-old man with mild COVID-19 is described in this report. He died of a secondary infection with Fusobacterium necrophorum bacteremia and a progressive hemorrhagic disorder. The diagnosis was made based on the clinical course and needle necropsy results. In non-severe COVID-19 patients, rapid deterioration of the disease symptoms requiring emergency treatment should lead to suspicion of additional fatal infections with similar clinical symptoms.

Case report: Severe respiratory failure caused by licorice.

Licorice, one of the most commonly used herbs, can cause hypokalemia, metabolic alkalosis, and apparent mineralocorticoid excess, also known as pseudoaldosteronism. Herein, we present a case of diaphragmatic dysfunction caused by licorice administration. An 80-year-old woman who had been taking dietary supplements and following a restricted diet for approximately 6 months was brought to the emergency department with impaired consciousness. Chronic respiratory acidosis was observed, and hypertension and hypokalemia became more prominent during hospitalization. History revealed that she was taking herbal medicines containing licorice. Based on the results of hormone tests, the patient was diagnosed with pseudoaldosteronism. Chest radiography and pulmonary function tests confirmed the clinical diagnosis of diaphragmatic dysfunction. The metabolic alkalosis resulting from licorice administration may have contributed to the impairment of the respiratory muscles. This case suggests that caution should be exercised when using licorice in patients with preexisting health or medical issues such as advanced age, malnutrition, and electrolyte imbalance.

Delayed diagnosis of severe diabetic ketoacidosis associated with a sodium-glucose cotransporter 2 inhibitor: a case report.

Sodium-glucose cotransporter 2 (SGLT2) inhibitors are used to treat patients with type 2 diabetes mellitus but may induce diabetic ketoacidosis (DKA). Owing to their pharmacological mechanisms, they cause a different pathogenesis to that of typical DKA and require special attention in terms of blood glucose concentrations and acidosis. We describe a case of prolonged acidosis because of failure to immediately discover the use of an SGLT2 inhibitor. Compared with typical DKA, SGLT2 inhibitor-associated DKA requires earlier and longer glucose supplementation. SGLT2 inhibitors are specific aetiological factors in DKA, and their use should be suspected when the patient presents with mild hyperglycaemia or prolonged acidosis.

Invasive candidiasis presenting bronchiectatic cavity as chest radiological findings: A case report.

Invasive candidiasis is rare but is associated with high mortality in immunocompromised or critically ill patients. Here, we present a case of a 55-year-old man with untreated diabetes who was diagnosed with coronavirus disease 2019 and subsequently developed invasive candidiasis. The patient presented with fever, tachycardia, and tachypnea. Chest computed tomography revealed multiple consolidations mainly distributed around the bronchovascular bundles with bronchiectatic cavity formation, which initially raised suspicion for invasive pulmonary aspergillosis. However, subsequent testing confirmed Candida albicans infection; hence, we changed the antifungal agents effective for invasive candidiasis. This improved the patient's respiratory status, and he was then successfully weaned from mechanical ventilation. This case report highlights the importance of considering invasive candidiasis in the differential diagnosis of patients with bronchiectatic cavities on chest computed tomography, particularly in immunocompromised or critically ill patients with risk factors for invasive candidiasis.

Impact of COVID-19 pandemic on the care of severe burns in Japan: Repeated survey of specialized burn care facilities.

BACKGROUND: The spread of coronavirus disease 2019 (COVID-19), which began in 2020, has had a major impact on healthcare systems. The spread of COVID-19 has been reported to have affected the readiness to treat patients with burns worldwide. However, the existing reports have evaluated burn care status within a limited time period during the pandemic, and no report clarifies the change in the impact of infection status on burn care from the beginning of the pandemic to the present. METHODS: Japanese Society for Burn Injuries-accredited burn care facilities were surveyed using questionnaires on April 9-23, 2020; June 23-July 6, 2020; July 9-21, 2021; and January 21-31, 2022. Differences between groups were evaluated using Friedman's test or Bonferroni's multiple comparison test, as appropriate. RESULTS: From the 103 facilities included in the study, we received 85, 55, 56, and 58 responses in the first, second, third, and fourth surveys, respectively. We could continuously observe 34 facilities. The rate of acceptance of patients with severe burns improved significantly over time (P < 0.05). However, in the second and third surveys, there was an increase in the number of respondents who did not accept patients with burns irrespective of COVID-19 status. CONCLUSIONS: The number of facilities treating patients with burns who have COVID-19 is increasing; however, COVID-19 care may negatively impact routine burn care. It is necessary to continuously examine medical resource allocation through methods such as information sharing by academic societies.

Instructor Development Workshops for Advanced Life Support Training Courses Held in a Fully Virtual Space: Observational Study.

BACKGROUND: Various face-to-face training opportunities have been lost due to the COVID-19 pandemic. Instructor development workshops for advanced resuscitation (ie, advanced life support) training courses are no exception. Virtual reality (VR) is an attractive strategy for remote training. However, to our knowledge, there are no reports of resuscitation instructor training programs being held in a virtual space. OBJECTIVE: This study aimed to investigate the learning effects of an instructor development workshop that was conducted in a virtual space. METHODS: In this observational study, we created a virtual workshop space by using NEUTRANS (Synamon Inc)-a commercial VR collaboration service. The instructor development workshop for the advanced life support training course was held in a virtual space (ie, termed the VR course) as a certified workshop by the Japanese Association of Acute Medicine. We asked 13 instructor candidates (students) who participated in the VR course to provide a workshop report (VR group). Reports from a previously held face-to-face workshop (ie, the face-to-face course and group) were likewise prepared for comparison. A total of 5 certified instructor trainers viewed and scored the reports on a 5-point Likert scale. RESULTS: All students completed the VR course without any problems and received certificates of completion. The scores for the VR group and the face-to-face group did not differ at the level of statistical significance (median 3.8, IQR 3.8-4.0 and median 4.2, IQR 3.9-4.2, respectively; P=.41). CONCLUSIONS: We successfully conducted an instructor development workshop in a virtual space. The degree of learning in the virtual workshop was the same as that in the face-to-face workshop.

Development of virtual reality content for learning Japan Prehospital Trauma Evaluation and Care initial assessment procedures.

Aim: The Japan Prehospital Trauma Evaluation and Care (JPTEC) is a standardized educational program for prehospital trauma care in Japan. The initial assessment in the JPTEC course comprises a training segment that includes a 30-min session. Given the limited face-to-face training due to the coronavirus disease 2019, virtual reality (VR) content has become an alternative. However, creating VR content typically requires the assistance of expert technicians. We aimed to create VR content for the initial assessment segment of the JPTEC and verify its educational effectiveness. Methods: We created VR content for learning the initial assessment of the JPTEC using our easy-to-use VR content creation system. The participants played the VR content for 15 min. The number of times they "cleared" (i.e., made a correct decision and completed the initial assessment) was recorded every 5 min. Then, a JPTEC-certified instructor tested their practical skills through face-to-face simulation. Results: The authors had no specialized skills and created the VR content in 2 days. Fourteen students used the material. They cleared the scenario 3 (3-4) times in the first 5 min in 15 min, 5 (4-5) times in the second 5 min, and 5 (5-5) times in the third 5 min (P < 0.05). All participants passed the practical evaluation. Conclusion: A shorter VR training developed using our easy-to-use VR content creation system can replace the 30-min JPTEC session on the initial assessment. This system allows for the free and easy creation of VR content.

Medicine at mass gatherings: current progress of preparedness of emergency medical services and disaster medical response during 2020 Tokyo Olympic and Paralympic Games from the perspective of the Academic Consortium (AC2020).

Mass gatherings are events characterized by "the concentration of people at a specific location for a specific purpose over a set period of time that have the potential to strain the planning and response resources of the host country or community." Previous reports showed that, as a result of the concentration of people in the limited area, injury and illness occurred due to several factors. The response plan should aim to provide timely medical care to the patients and to reduce the burden on emergency hospitals, and to maintain a daily emergency medical services system for residents of the local area. Although a mass gathering event will place a significant burden on the local health-care system, it can provide the opportunity for long-term benefits of public health-care and improvement of daily medical service systems after the end of the event. The next Olympic and Paralympic Games will be held in Tokyo, during which mass gatherings will occur on a daily basis in the context of the coronavirus disease (COVID-19) epidemic. The Academic Consortium on Emergency Medical Services and Disaster Medical Response Plan during the Tokyo Olympic and Paralympic Games in 2020 (AC2020) was launched 2016, consisting of 28 academic societies in Japan, it has released statements based on assessments of medical risk and publishing guidelines and manuals on its website. This paper outlines the issues and countermeasures for emergency and disaster medical care related to the holding of this big event, focusing on the activities of the academic consortium.

The effect of chitosan hydrogel containing DMEM/F12 medium on full-thickness skin defects after deep dermal burn.

Burn wound excision is considered necessary to prepare skin for grafting, and the success of graft "take" is thought to be dependent on the vascular supply to the wound. We previously showed that photocrosslinkable chitosan hydrogel containing DMEM/F12 medium (medium-Az-CH-LA) is a biocompatible and biodegradable biomaterial that promotes re-epithelialization and neovascularization. The current study was designed to determine the effect of medium-Az-CH-LA on deep dermal burn. Sixteen male Wistar rats were randomly divided into two groups that were treated with medium-Az-CH-LA (n=5) or a collagen sponge (n=5). Under anesthesia, the dorsal fur was shaved and the skin was exposed to water at 95 degrees C for 10s. After 2h, damaged tissue was removed from the fascia and dressed with medium-Az-CH-LA or a collagen sponge. Specimens were obtained after 2, 4, 6, 8, 12, 16 and 32 days for histological analysis. There was no significant difference in the time required for wound closure between the two groups, but the thickness of the granulation tissue in the medium-Az-CH-LA-treated group was greater than that in the collagen sponge-treated group. Moreover, degradation and neovascularization occurred earlier in the group treated with medium-Az-CH-LA compared with the collagen sponge-treated group. These findings suggest that early degradative and angiogenic activities of medium-Az-CH-LA may be beneficial for granulation tissue formation in deep dermal burn wounds.