Caution for psychiatrists: malignant hyperthermia risks with the anesthetic agent succinylcholine (Suxamethonium) during electroconvulsive therapy.

BACKGROUND: Malignant hyperthermia is a potentially lethal condition triggered by specific anesthetic drugs, especially a depolarizing muscle relaxant of succinylcholine (Suxamethonium). Despite the frequent use of succinylcholine with electroconvulsive therapy (ECT), there has been no reported case of potentially lethal malignant hyperthermia following ECT. In addition, the time interval between the administration of succinylcholine and the onset of malignant hyperthermia has not been outlined in the context of ECT. CASE PRESENTATION: We present the case of a 79-year-old woman suffering from severe depression, who experienced severe malignant hyperthermia due to succinylcholine administration during an ECT session. She presented with a high fever of 40.2 °C, tachycardia of 140/min, hypertension with a blood pressure exceeding 200 mmHg, significant muscle rigidity, and impaired consciousness. These symptoms emerged two hours after ECT, which occurred in a psychiatric ward rather than an operating room, and reached their peak in less than 24 h. She was given 60 mg of dantrolene, which quickly reduced the muscular rigidity. Subsequently, she received two additional doses of 20 mg and 60 mg of dantrolene, which brought her fever down to 36.2 °C and completely eased her muscle rigidity within two days after ECT. CONCLUSIONS: This is the first reported case of potentially lethal malignant hyperthermia after ECT. In addition, it highlights the delayed onset of malignant hyperthermia following an ECT procedure, emphasizing the necessity for psychiatrists to recognize its onset even after the treatment. In the light of potentially lethal consequences of malignant hyperthermia, it is critically important for psychiatrists to closely monitor both intraoperative and postoperative patient's vital signs and characteristic physical presentations, promptly identify any symptomatic emergence, and treat it immediately with dantrolene.

Caution to psychiatry ward: COVID-19 pneumonia can manifest weeks or months after testing positive with a PCR test in individuals on preexisting immune-suppressing medication.

Background: Some patients are reported to develop depression immediately after COVID-19 infection. Typically, hospitalization is arranged a week to 10 days after symptom onset to avoid outbreak in the psychiatric ward when infectivity is almost eliminated. However, in patients on immunosuppressive drugs, infection is known to persist beyond the 10th day after testing positive with a polymerase chain reaction (PCR) test. Case Presentation: We present a patient with follicular lymphoma who was receiving immune-suppressing medication and contracted a COVID-19 infection; she developed severe depression and eventually required hospitalization 10 days after symptom onset or 5 days after the COVID-19 infection-related symptoms disappeared. Although the patient did not exhibit any symptom of pneumonia upon admission, she developed COVID-19 pneumonia 3 weeks after the initial positive test. She received intravenous infusion of the antiviral drug remdesivir, which led to the improvement of pneumonia, and she was discharged on day 32 from testing COVID-19 positive. However, COVID-19 pneumonia recurred on days 64 and 74. Conclusion: This is the first report of COVID-19 pneumonia developing in a psychiatric ward in a patient on immunosuppressive drugs, weeks to months after testing positive with a PCR test. When patients with compromised immune function, such as those on immunosuppressant medication or those with human immunodeficiency virus disease, are admitted to a psychiatric ward, careful monitoring of the risk of recurrence and sufficient consideration for infection control measures are necessary to avoid outbreaks.

COVID-19-associated leukoencephalopathy in the absence of severe hypoxia with subsequent improvement: a case report.

BACKGROUND: Several cases of coronavirus disease 2019 (COVID-19)-associated leukoencephalopathy have been reported. Although most cases involve hypoxia, the pathophysiological mechanism and neurologic outcomes of COVID-19-associated leukoencephalopathy remain unclear. CASE PRESENTATION: We report a case of COVID-19-associated leukoencephalopathy without severe hypoxia in a 65-year-old woman diagnosed with pyelonephritis. After the initiation of intravenous ceftriaxone, her fever resolved, but she developed an altered state of consciousness with abnormal behavior and, subsequently, a relapse fever. She was diagnosed with COVID-19 pneumonia and was intubated. Lung-protective ventilation with deep sedation and neuromuscular blockade were used for treatment. After cessation of sedative administration, her mental status remained at a Glasgow Coma Scale score of 3. COVID-19 was assumed to have caused leukoencephalopathy due to the absence of severe hypoxia or other potential causes. She subsequently showed gradual neurologic improvement. Three months after the COVID-19 diagnosis, she regained alertness, with a Glasgow Coma Scale score of 15. CONCLUSION: Clinicians should consider leukoencephalopathy in the differential diagnosis of consciousness disorders in patients with severe COVID-19, even in the absence of severe hypoxia. Gradual neurologic improvement can be expected in such cases.

A new screening model for quantitative risk assessment of blunt thoracic aortic injury.

PURPOSE: Early identification of blunt thoracic aortic injury is vital for preventing subsequent aortic rupture. However, risk factors for blunt thoracic aortic injury remain unclear, and a prediction rule remains to be established. We developed and internally validated a new nomogram-based screening model that allows clinicians to quantify blunt thoracic aortic injury risk. METHODS: Adult patients (age ≥ 18 years) with blunt injury were selected from a nationwide Japanese database (January 2004-May 2019). Patients were randomly divided into training and test cohorts. A new nomogram-based blunt thoracic aortic injury-screening model was constructed using multivariate logistic regression analysis to quantify the association of potential predictive factors with blunt thoracic aortic injury in the training cohort. RESULTS: Overall, 305,141 patients (training cohort, n = 152,570; test cohort, n = 152,571) were eligible for analysis. Median patient age was 65 years, and 60.9% were men. Multivariate analysis in the training cohort revealed that 13 factors (positive association: age ≥ 55 years, male sex, high-energy impact, hypotension on hospital arrival, Glasgow Coma Scale score < 9 on hospital arrival, diaphragmatic injuries, hepatic injuries, pulmonary injuries, cardiac injuries, renal injuries, sternum fractures, multiple rib fractures, and pelvic fractures) were significantly associated with blunt thoracic aortic injury and included in the screening model. In the test cohort, the new screening model had an area under the curve of 0.87. CONCLUSIONS: Our novel nomogram-based screening model aids in the quantitative assessment of blunt thoracic aortic injury risk. This model may improve tailored decision-making for each patient.

Evaluation of initial shockable rhythm as an indicator of short no-flow time in cardiac arrest: a national registry study.

BACKGROUND: The duration from collapse to initiation of cardiopulmonary resuscitation (no-flow time) is one of the most important determinants of outcomes after out-of-hospital cardiac arrest (OHCA). Initial shockable cardiac rhythm (ventricular fibrillation or ventricular tachycardia) is reported to be a marker of short no-flow time; however, there is conflicting evidence regarding the impact of initial shockable cardiac rhythm on treatment decisions. We investigated the association between initial shockable cardiac rhythm and the no-flow time and evaluated whether initial shockable cardiac rhythm can be a marker of short no-flow time in patients with OHCA. METHODS: Patients aged 18 years and older experiencing OHCA between 2010 and 2016 were selected from a nationwide population-based Japanese database. The association between the no-flow time duration and initial shockable cardiac rhythm was evaluated. Diagnostic accuracy was evaluated using the sensitivity, specificity and positive predictive value. RESULTS: A total of 177 634 patients were eligible for the analysis. The median age was 77 years (58.3%, men). Initial shockable cardiac rhythm was recorded in 11.8% of the patients. No-flow time duration was significantly associated with lower probability of initial shockable cardiac rhythm, with an adjusted OR of 0.97 (95% CI 0.96 to 0.97) per additional minute. The sensitivity, specificity and positive predictive value of initial shockable cardiac rhythm to identify a no-flow time of <5 min were 0.12 (95% CI 0.12 to 0.12), 0.88 (95% CI 0.88 to 0.89) and 0.35 (95% CI 0.34 to 0.35), respectively. The positive predictive values were 0.90, 0.95 and 0.99 with no-flow times of 15, 18 and 28 min, respectively. CONCLUSIONS: Although there was a significant association between initial shockable cardiac rhythm and no-flow time duration, initial shockable cardiac rhythm was not reliable when solely used as a surrogate of a short no-flow time duration after OHCA.

External validation of simplified out-of-hospital cardiac arrest and cardiac arrest hospital prognosis scores in a Japanese population: a multicentre retrospective cohort study.

BACKGROUND: The novel simplified out-of-hospital cardiac arrest (sOHCA) and simplified cardiac arrest hospital prognosis (sCAHP) scores used for prognostication of hospitalised patients have not been externally validated. Therefore, this study aimed to externally validate the sOHCA and sCAHP scores in a Japanese population. METHODS: We retrospectively analysed data from a prospectively maintained Japanese database (January 2012 to March 2013). We identified adult patients who had been resuscitated and hospitalised after intrinsic out-of-hospital cardiac arrest (OHCA) (n=2428, age ≥18 years). We validated the sOHCA and sCAHP scores with reference to the original scores in predicting 1-month unfavourable neurological outcomes (cerebral performance categories 3-5) based on the discrimination and calibration measures of area under the receiver operating characteristic curves (AUCs) and a Hosmer-Lemeshow goodness-of-fit test with a calibration plot, respectively. RESULTS: In total, 1985/2484 (82%) patients had a 1-month unfavourable neurological outcome. The original OHCA, sOHCA, original cardiac arrest hospital prognosis (CAHP) and sCAHP scores were available for 855/2428 (35%), 1359/2428 (56%), 1130/2428 (47%) and 1834/2428 (76%) patients, respectively. The AUCs of simplified scores did not differ significantly from those of the original scores, whereas the AUC of the sCAHP score was significantly higher than that of the sOHCA score (0.88 vs 0.81, p<0.001). The goodness of fit was poor in the sOHCA score (ν=8, χ2=19.1 and Hosmer-Lemeshow test: p=0.014) but not in the sCAHP score (ν=8, χ2=13.5 and Hosmer-Lemeshow test: p=0.10). CONCLUSION: The performances of the original and simplified OHCA and CAHP scores in predicting neurological outcomes in successfully resuscitated OHCA patients were acceptable. With the highest availability, similar discrimination and good calibration, the sCAHP score has promising potential for clinical implementation, although further validation studies to evaluate its clinical acceptance are necessary.

Nursing Home Versus Community Resuscitation After Cardiac Arrest: Comparative Outcomes and Risk Factors.

OBJECTIVE: To investigate the characteristics and outcomes of patients who experienced cardiac arrest in nursing homes compared with those in private residences and determine prognostic factors for survival. DESIGN: This was a retrospective study that analyzed data from an Utstein-style registry of the Tokyo Fire Department. SETTING AND PARTICIPANTS: We identified patients aged ≥65 years who experienced cardiac arrest in a nursing home or private residence from the population-based registry of out-of-hospital cardiac arrests in Tokyo, Japan, from 2014 to 2018. METHODS: Patients were grouped into the nursing home or the private residence groups according to their cardiac arrest location. We compared the characteristics and outcomes between the 2 groups and determined prognostic factors for survival in the nursing home group. The primary outcome was 1-month survival after cardiac arrest. RESULTS: In total, 37,550 patient records (nursing home group = 6271; private residence group = 31,279) were analyzed. Patients in the nursing home group were significantly older and more often had witnessed arrest, bystander cardiopulmonary resuscitation (CPR), and shock delivery using an automated external defibrillator. The 1-month survival rate was significantly higher in the nursing home group (2.6% vs 1.8%, P < .001). In the best scenario (daytime emergency call, witnessed cardiac arrest, bystander CPR provided), the 1-month survival rate after cardiac arrest in the nursing home group was 8.0% (95% confidence interval 6.4-9.9%), while none survived if they had neither witness nor bystander CPR. CONCLUSIONS AND IMPLICATIONS: Survival outcome was significantly better in the nursing home group than in the private residence group and was well stratified by 3 prognostic factors: emergency call timing, witnessed status, and bystander CPR provision. Our results suggest that a decision to withhold vigorous treatment solely based on nursing home residential status is not justified, while termination of resuscitation may be determined by considering significant prognostic factors.

Comorbid Psychiatric Disorders in Patients Hospitalized for Pulmonary Embolism and Acute Myocardial Infarction: A Japanese Nationwide Database Study.

Objective: While the most common cause of sudden cardiac arrest (SCA) in the general population is ischemic cardiac disease including acute myocardial infarction (AMI), previous preliminary data highlighted pulmonary embolism (PE) as a common cause of SCA among psychiatric patients. The aim of this study was to examine the proportion of patients with comorbid psychiatric disorders among patients hospitalized for either AMI or PE using a Japanese nationwide database.Methods: This study used Diagnosis Procedure Combination (DPC) data between April 2013 and March 2018 provided by the Ministry of Health, Labor, and Welfare. The DPC data included information on the causes of hospitalization and comorbidities of psychiatric diseases among inpatients in all acute care hospitals in Japan. The proportions of patients with schizophrenia (ICD-10 code F20), mood disorders (F31 or F32), and no psychiatric disorders were analyzed among patients who were hospitalized for AMI and PE.Results: The data from 351,159 AMI patients (mean age = 70.3 years) and 52,036 PE patients (mean age = 69.2 years) were used. Mortality rates were 8.0%-14.4% in AMI patients and 4.3%-9.8% in PE patients. The AMI group was predominantly male. The proportions of patients with schizophrenia and mood disorder were significantly higher in the PE group than in the AMI group (schizophrenia: 2.53% [1,314/52,036] vs 0.55% [1,922/351,159], P < .001; mood disorder: 2.94% [1,532/52,036] vs 0.60% [2,099/351,159], P < .001).Conclusions: The results highlight the importance of PE as a major cause of SCA in this specific population and the need for preventive measures to mitigate the mortality gap among patients with psychiatric disorders.

Development of a risk stratification scoring system for deep vein thrombosis upon psychiatric admission.

AIM: Psychiatric patients have increased risk of deep vein thrombosis (DVT). However, there is no systematic data on risk assessment of DVT among psychiatric inpatients. The aim of this study was to develop a risk stratification scoring system for DVT among psychiatic patients on admission. METHODS: A systematic review of psychiatric patient's charts, who were admitted to the Tokyo Metropolitan Matsuzawa Hospital from June 2012 to February 2016 and underwent screening for DVT, was conducted. Patients were randomly divided into development (n = 2634) and validation (n = 2634) groups. Estimated risk values in the multiple logistic regression model for the development sample were rounded to the nearest integer, and used as points of associated factors in the risk stratification scoring system; the total scores were tested in the validation sample. The score's discriminatory ability was assessed with the area under the receiver operating characteristic curve (AUC). RESULTS: Among the 5268 patients, 258 (4.9%) had DVT. Advancing age, female sex, active cancer, previous venous thromboembolism, transfer from a general hospital, catatonia, and major depressive episode were all significantly associated with the presence of DVT in the development sample. The total score showed good discriminatory ability in the validation sample (AUC: 0.816, 95% confidence interval: 0.781-0.851); scores of 0-1, 2-3, 4-5, and ≥ 6 were associated with very low risk (0.7%), low risk (4.6%), moderate risk (14.9%), and high risk (35%) for DVT, respectively. CONCLUSION: Our risk stratification scoring system showed good performance for detection of DVT among psychiatric patients on admission.

Effectiveness of public-access automated external defibrillators at Tokyo railroad stations.

AIM: To investigate the effectiveness of public-access automated external defibrillators (AEDs) at Tokyo railroad stations. METHODS: We analysed data from a population-based registry of out-of-hospital cardiac arrests in Tokyo, Japan (2014-2018). We identified patients aged ≥18 years who experienced bystander-witnessed cardiac arrest due to ventricular fibrillation of presumed cardiac origin at railroad stations. The primary outcome was survival at 1 month after cardiac arrest with favourable neurological outcomes (cerebral performance category 1-2). RESULTS: Among 280 eligible patients who had bystander-witnessed cardiac arrest and received defibrillation at railroad stations, 245 patients (87.5%) received defibrillation using public-access AEDs and 35 patients (12.5%) received defibrillation administered by emergency medical services (EMS). Favourable neurological outcomes at 1 month after cardiac arrest were significantly more common in the group that received defibrillation using public-access AEDs (50.2% vs. 8.6%; adjusted odds ratio: 11.2, 95% confidence interval: 1.43-88.4) than in the group that received defibrillation by EMS. Over a 5-year period, favourable neurological outcomes at 1 month after cardiac arrest of 101.9 cases (95% confidence interval: 74.5-129.4) were calculated to be solely attributable to public-access AED use. The incremental cost-effectiveness ratio to gain one favourable neurological outcome obtained from public-access AEDs at railroad stations was lower than that obtained from nationwide deployment (48.5 vs. 2133.4 AED units). CONCLUSION: Deploying public-access AEDs at Tokyo railroad stations presented significant benefits and cost-effectiveness. Thus, it may be prudent to prioritise metropolitan railroad stations in public-access defibrillation programs.

Older Adults with Traumatic Brain Injury in the Most Aged and Most Rapidly Aging Country: An Analysis of the Nationwide Trauma Registry of Japan.

BACKGROUND: Despite the increasing numbers of older adults with traumatic brain injury (TBI), minimal data are available to support the development of treatment strategies. We aimed to comprehensively describe the incidence, characteristics, outcomes, and predictive accuracy of the severity indicators among older adults with TBI. METHODS: Using the Japan Trauma Data Bank, we identified patients aged ≥18 years with TBI from 2004 to 2019. The patients were grouped according to age, and their baseline characteristics, radiological findings, severity, complications, and in-hospital mortality were assessed. Receiver operating characteristic curves were used to assess the accuracy of severity indicators for predicting in-hospital mortality. RESULTS: Of the 94,180 patients who met the inclusion criteria, 50,990 (54.1%) were older adults (aged ≥65 years). Their proportion had increased at 2.1% annually, which exceeded the 0.5% annual increase in the general population. The proportion of women and the prevalence of comorbidities increased significantly with age. Traffic accidents were the leading cause of TBI among young adults, and falling at ground level was the leading cause for those aged ≥75 years. The radiological findings were significantly different among the age groups. The proportion of acute epidural hemorrhage, skull fracture, and diffuse axonal injury decreased and that of acute subdural hemorrhage increased with age. The predictive accuracy of the Glasgow coma scale, revised trauma score, and injury severity score decreased with increasing age. CONCLUSIONS: The proportion of older patients with TBI increased more quickly than did the proportion of older people in the general population. The characteristics and predictive accuracy of the severity indicators differed significantly among the different age groups. TBI studies that focus on older patients are necessary.

Pre-existing psychiatric disorder is related to lower mortality from road traffic accident: A Japanese nationwide retrospective cohort study.

BACKGROUND: Previous studies have reported inconsistent results on the mortality from trauma among psychiatric patients comparing to non-psychiatric population, which may be partly explained by the inclusion of both suicidal and accidental trauma. This study aimed to investigate the association of psychiatric diagnoses on admission with the outcomes of hospitalized patients for accidental trauma, namely road traffic injury. METHODS: Detailed information of patients aged 15 years or older who were hospitalized for road traffic injury between 2004 and 2017 was extracted from the Japan Trauma Data Bank. The primary outcome was to compare in-hospital mortality between patients with and without a psychiatric disorder. We also conducted a subgroup analysis among patients with and without a serious head injury. RESULTS: Altogether, 85,069 patients were included. Of these, 3,895 patients (4.6%) had a psychiatric diagnosis. The in-hospital mortality rate was significantly lower among patients with a psychiatric diagnosis than those without (5.4% vs. 8.3%; adjusted odds ratio [OR] 0.57, 95% confidence interval [CI] 0.47-0.70, p<0.001). In a subgroup analysis of patients with a serious head injury, in-hospital mortality was significantly lower in patients with a psychiatric diagnosis than in those without (10.5% vs. 17.3%; adjusted OR 0.48, 95% CI 0.37-0.62, p<0.001); in-hospital mortality of patients without a serious head injury showed no differences between patients with or without a psychiatric diagnosis (2.8% vs. 3.5%; adjusted OR 0.84, 95% CI 0.61-1.16, p=0.295). CONCLUSIONS: In-hospital mortality from road traffic injury was significantly lower among patients with a psychiatric diagnosis than those without, which was primarily evident in a subgroup of patients with a serious head injury. While further replication is necessary, results might be indicative of the neuroprotective effect of psychotropic medications.

Derivation and validation of a quantitative screening model for blunt cerebrovascular injury.

OBJECTIVE: The objective of this study was to derive and validate a new screening model using a nomogram that allows clinicians to quantify the risk of blunt cerebrovascular injury (BCVI). METHODS: In this study, the authors examined 258,935 patients from a prospectively collected nationwide Japanese database (January 2009-December 2018) who experienced blunt injury. Patients were randomly divided into training (n = 129,468) and validation (n = 129,467) cohorts. First, the authors investigated the prevalence of BCVI, which was defined as blunt injury to any intracranial vessel, the extracranial vertebral artery, the extracranial carotid (common, internal) artery, or the internal jugular vein. Then, a new arterial BCVI screening model using a nomogram was derived, based on multivariate logistic regression analysis through quantifying the association of potential predictive factors with BCVI in the training cohort. The model's discriminatory ability was validated using the area under the receiver operating characteristic curve (AUC) in the validation cohort. RESULTS: Multivariate analysis in the training cohort showed that 13 factors were significantly associated with arterial BCVI and were included in our model. These factors were 1) male sex; 2) high-energy impact; 3) hypotension on hospital arrival; 4) Glasgow Coma Scale score < 9; 5) injury to the face; 6) injury to the neck; 7) injury to the spine; 8) skull base fracture; 9) cervical spine fracture or subluxation; and those with negative associations, i.e., 10) injury to the lower-extremity region; 11) supratentorial subdural hemorrhage; 12) lumbar spine fracture or subluxation; and 13) soft tissue injury of the face. In the validation cohort, the model had an AUC of 0.83 (95% CI 0.81-0.86). When the definition of BCVI was narrowed to include only carotid (common, internal) and vertebral artery injuries, the AUC of the model in predicting these injuries was 0.89 (95% CI 0.87-0.91). CONCLUSIONS: A new screening model that incorporates an easy-to-use nomogram to quantify the risk of BCVI and assist clinicians in identifying patients who warrant additional evaluation was established.

Critically ill patients with COVID-19 in Tokyo, Japan: A single-center case series.

INTRODUCTION: We reported, in our previous study, a patient with coronavirus disease 2019 (COVID-19) who was successfully treated with extracorporeal membrane oxygenation. Data on clinical courses and outcomes of critically ill patients with COVID-19 in Japan are limited in the literature. This study aimed to describe the clinical courses and outcomes of critically ill patients with COVID-19 in Tokyo, Japan. METHODS: This is a single-center case series study. Patients with COVID-19 treated with mechanical ventilation (MV) were reviewed retrospectively. Data on baseline characteristics, in-hospital treatment, and outcomes were collected. RESULTS: Between February 2, 2020, and June 30, 2020, 14 critically ill patients with COVID-19 were treated with MV. Most patients were male and had comorbidities, especially hypertension or diabetes; 35.7% were overweight and 21.4% were obese. The majority of the patients had dyspnea on admission. The median duration of MV was 10.5 days, and the 28-day mortality rate was 35.7%. In the four patients with COVID-19 who died, the cause of death was respiratory failure. CONCLUSIONS: As in previous reports from other countries, the mortality rate of patients with COVID-19 requiring intensive care remains high in Tokyo. Further study on the appropriate timing of MV initiation and specific treatments for critically ill patients with COVID-19 is needed.

Lower mortality from suicidal trauma among patients with a psychiatric diagnosis upon admission: Nationwide japanese retrospective cohort study.

Suicide and self-harm are major public health issues. Few studies have compared mortality from suicidal trauma between patients with and without contact with psychiatric services. This study aimed to compare the in-hospital mortality of suicidal trauma between patients with and without a psychiatric diagnosis upon hospital admission. Data on 15- to 90-year-old patients with suicidal trauma between 2004 and 2015 was extracted from the Japan Trauma Data Bank. In-hospital mortality were compared between patients with and without a psychiatric diagnosis. A total of 9,803 patients were included. The median age was 42 years (interquartile range: 29-59), and 5,010 patients (51.1%) were male. The most frequent method of injury was falling from a height (53.4%), followed by stabbing (32.3%) and burns (6.2%). In total, 4,878 patients (49.8%) had a psychiatric diagnosis upon admission. The proportion of patients with a psychiatric diagnosis was significantly lower among males, teenagers, and older people. In-hospital mortality was significantly lower among patients with a psychiatric diagnosis than those without (10.9%vs18.7%). Contact with psychiatric services might be protective among people with suicidal trauma. However, the proportion of psychiatric service use was generally low. These findings show the importance of delivering appropriate psychiatric services to high-risk patients.

A sporadic COVID-19 pneumonia treated with extracorporeal membrane oxygenation in Tokyo, Japan: A case report.

INTRODUCTION: An ongoing outbreak of a novel coronavirus disease (coronavirus disease 2019, COVID-19) has become a global threat. While clinical reports from China to date demonstrate that the majority of cases remain relatively mild and recover with supportive care, it is also crucial to be well prepared for severe cases warranting intensive care. Initiating appropriate infection control measures may not always be achievable in primary care or in acute-care settings. CASE: A 45-year-old man was admitted to the intensive care unit due to severe pneumonia, later confirmed as COVID-19. His initial evaluation in the resuscitation room and treatments in the intensive care unit was performed under droplet and contact precaution with additional airborne protection using the N95 respirator mask. He was successfully treated in the intensive care unit with mechanical ventilation and extracorporeal membrane oxygenation for respiratory support; and antiretroviral treatment with lopinavir/ritonavir. His total intensive care unit stay was 15 days and was discharged on hospital day 24. CONCLUSIONS: Strict infection control precautions are not always an easy task, especially under urgent care in an intensive care unit. However, severe cases of COVID-19 pneumonia, or another novel infectious disease, could present at any moment and would be a continuing challenge to pursue appropriate measures. We need to be well prepared to secure healthcare workers from exposure to infectious diseases and nosocomial spread, as well as to provide necessary intensive care.

Life-Threatening Serotonin Syndrome Precipitated by Discontinuation of Serotonin-Dopamine Antagonist in the Presence of Serotonergic Agents: A Case Report.

INTRODUCTION: Serotonin syndrome is caused by excessive activation of serotonin (5-hydroxytryptamine [5-HT]) neurotransmission. Although the discontinuation of antipsychotics with 5-HT2 receptor antagonistic characteristics could theoretically result in serotonin syndrome, there have been very few reports on the syndrome thus far. CASE PRESENTATION: A 75-year-old woman with somatoform disorder was transferred to our emergency room because of pyrexia, unconsciousness, and myoclonus with hyperreflexia. She had been taking milnacipran and perospirone for 10 years and had started taking duloxetine 2 months before the event. Thereafter, she suffered diaphoresis, gait disturbance, and tremor. Her psychiatrist advised her to stop taking perospirone, because of suspicion of extrapyramidal symptoms, a day before admission. The clinical diagnosis of serotonin syndrome was made based on her symptoms while using serotonergic agents. Her symptoms were so severe that she was transferred to the intensive care unit, where supportive care was successful. CONCLUSIONS: Discontinuation of antipsychotics that are 5-HT2 receptor antagonists may lead to serotonin syndrome in patients who take serotonergic agents. As extrapyramidal symptoms and serotonin toxicity share some clinical features, detailed drug history and physical examination are necessary for successful treatment.

Private residence as a location of cardiac arrest may have a deleterious effect on the outcomes of out-of-hospital cardiac arrest in patients with an initial non-shockable cardiac rhythm: A multicentre retrospective cohort study.

AIM: We compared the outcomes between patients who experienced out-of-hospital cardiac arrest at private residences and public locations to investigate whether patient and bystander characteristics can explain the poorer outcomes of out-of-hospital cardiac arrests at private residences. METHODS: Adult patients with intrinsic out-of-hospital cardiac arrest (n = 6,191, age ≥18 years) were selected from a prospectively collected Japanese database (January 2012 and March 2013). Patients were grouped according to arrest location into private-residence or control (e.g., public station or road, workplace, school, and other public locations) groups. The primary outcome was a favourable neurological outcome 1 month after out-of-hospital cardiac arrest. RESULTS: The arrest location and initial cardiac rhythm had interaction effects on the outcome. After adjusting for patient and bystander characteristics and relative to the control group, a significantly poorer 1-month neurological outcome was observed in the private-residence group if the initial cardiac rhythm was non-shockable (odds ratio: 0.36, 95% confidence interval: 0.24-0.54), while it was not significant if the initial cardiac rhythm was shockable (odds ratio: 1.16, 95% confidence interval: 0.74-1.84). CONCLUSIONS: Patients with out-of-hospital cardiac arrest at private residences had poorer outcomes than those with out-of-hospital cardiac arrest at public locations, even after adjusting for patient and bystander characteristics, if the initial cardiac rhythm was non-shockable. Our results suggest that poorer patient and bystander characteristics do not completely explain the poorer outcomes of out-of-hospital cardiac arrests; there may be unknown mechanisms through which the location of cardiac arrest affect the outcomes.

Prehospital times and outcomes of patients who had hypotension at the scene after trauma: A nationwide multicentre retrospective study.

BACKGROUND: We aimed to investigate the association between prehospital times and outcomes of patients who had hypotension at the scene after trauma incidents. METHODS: We retrospectively analysed records from a nationwide database (2004-2017) of adults (aged ≥15 years) who were hypotensive (systolic blood pressure <90 mmHg) at the scene after trauma. The endpoint was in-hospital mortality. We used multivariable logistic regression analysis to adjust for confounding factors and to estimate the odds ratio (OR) of prehospital times for in-hospital mortality. Stratified analyses were performed based on patient age and type and severity of the trauma. RESULTS: Among 5,499 patients included, 906 (16.5%) died in the hospital. The median Injury Severity Score (ISS) was 17 (interquartile range, 9-29). There was a significant trend towards patients having higher in-hospital mortality and ISS when their prehospital times were shorter (P < 0.001). However, the association between prehospital times and in-hospital mortality was not significant after adjusting for confounding factors, with an adjusted odds ratio of 1.00 (95% confidence interval: 0.98-1.01) per 10 min increments in prehospital time. The association remained insignificant when patients were stratified according to age and type and severity of the trauma. CONCLUSIONS: Our analysis revealed that prehospital time was not significantly associated with in-hospital mortality among patients who had hypotension at the scene after trauma in the current emergency medical service system in Japan. Further studies are needed to validate our findings.