Clinico-demographic factors associated with the treatment response to cognitive behavioral therapy for insomnia.

BACKGROUND: Cognitive behavioral therapy for insomnia (CBT-I) is among the recommended non-pharmacological treatments for patients with insomnia. While there are multiple reports on the effects of CBT-I treatment, few studies evaluating the factors associated with the treatment response to CBT-I have been reported. The present study aimed to confirm the effects of CBT-I in patients with insomnia and to examine the clinico-demographic factors that can predict the outcomes of CBT-I in these patients. METHODS: Overall, 62 patients were included in the present study. To confirm the effectiveness of CBT-I, we compared the pre- and post-CBT-I therapy values of several sleep parameters. Furthermore, to identify the clinico-demographic factors that could be predictive of the treatment response to CBT-I, we performed generalized linear model (GLM) analysis. RESULTS: The values of several sleep parameters were significantly lower after treatment than at baseline. The results of the GLM analysis revealed that sex and occupation were significantly associated with the treatment response to CBT-I. CONCLUSIONS: The present results suggest that several clinico-demographic factors should be considered in the treatment of patients with insomnia.

Clinical characteristics of aneurysmal subarachnoid haemorrhage complicated by Takotsubo cardiomyopathy resulting in good neurological outcome.

BACKGROUND: Takotsubo cardiomyopathy (TC) is a well-known complication of subarachnoid haemorrhage (SAH), often accompanied by neurogenic myocardial dysfunction. Although TC has been reported to be associated with higher morbidity and mortality among patients with aneurysmal SAH (aSAH), some patients have been reported to recover, the profiles and follow-up outcomes of these survivors remain unclear. MATERIALS AND METHODS: To characterize the profiles of patients with aSAH complicated by TC who experienced favourable outcomes using long-term follow-up data, a consecutive series of patients with aSAH were enrolled and TC diagnosis was based on the revised version of the Mayo Clinic criteria. Clinical outcomes were assessed at 6 months according to modified Rankin Scale scores. RESULTS: Among 165 consecutive patients with aSAH, 15 cases were complicated by TC, corresponding to an occurrence rate of 9.0%. Five patients with aSAH complicated by TC (33.3%) experienced a favourable outcome, and the mean value of systolic blood pressure on arrival was significantly lower than in those who experienced an unfavourable outcome (p = 0.032). CONCLUSION: According to analysis, it is possible cardiac dysfunction with decreased cerebral perfusion pressure and catecholamine toxicity transiently worsens conscious disturbance in aSAH complicated by TC. Therefore, it is important to carefully screen patients with aSAH to identify those complicated by TC, and for close collaboration of the multidisciplinary team to design appropriate treatment strategies.

Continuous positive airway pressure treatment from the prehospital field in a Japanese regional Doctor Car system.

Background: Continuous positive airway pressure (CPAP) therapy is an effective treatment for patients with severe heart failure, and certain guidelines recommend its early initiation. However, the current Japanese law strictly prohibits paramedics from administering this treatment. To demonstrate the efficacy and safety of prehospital administration of CPAP therapy, this study was conducted by the Yokohama Medical Control Council (Yokohama MC). Methods: The Yokohama MC established a protocol for CPAP treatment and dispatched Doctor Cars to attend to patients with severe respiratory failure. The Boussignac CPAP system was installed in all Yokohama Doctor Cars, including Workstation-type Doctor Cars and Hospital-type Doctor Cars. Data from this study were collected and recorded in the Yokohama City Doctor Car Registry system from October 2020 to January 2022. Results: The Doctor Car was dispatched 661 times, and CPAP therapy was administered to 13 patients in the prehospital field. It is important to note that the number of CPAP cases was lower than anticipated due to the coronavirus disease 2019 (COVID-19) pandemic, given concerns about aerosol production. When assessing changes over time in oxygen saturation (SpO2), the median (interquartile range), excluding missing values, was 89% (83%-93%) without oxygen, 95% (94%-99.3%) with oxygen, and 100% (97%-100%) with CPAP. The differences between these groups were statistically significant with a p-value of <0.0001. Respiratory distress was primarily attributed to heart failure in 10 patients (91%) and pneumothorax in 1 patient (9%). Notably, none of the patients' conditions worsened after the use of CPAP. Conclusion: We have detailed the administration of CPAP therapy in the prehospital field within a local city in Japan. To the best of our knowledge, this represents the inaugural report of a prospective observational study on the prehospital administration of CPAP therapy originating from Japan.

Diagnosis and treatment approaches for simultaneous onset of subarachnoid hemorrhage and thyroid storm: a case report.

BACKGROUND: Subarachnoid hemorrhage and thyroid storm are similar in their clinical symptomatology, and diagnosis of these conditions, when they occur simultaneously, is difficult. Here, we report a rare case of concurrent subarachnoid hemorrhage and thyroid storm we encountered at our hospital. CASE PRESENTATION: The patient was a 52-year-old woman. While bathing at home, the patient experienced a sudden disturbance of consciousness and was brought to our hospital. The main physical findings upon admittance were Glasgow Coma Scale score of E1V2M4, elevated blood pressure (208/145 mmHg), and tachycardia with atrial fibrillation (180 bpm) along with body temperature of 36.1 °C. Brain computed tomography revealed subarachnoid hemorrhage associated with a ruptured aneurysm of the posterior communicating artery branching from the left internal carotid artery, and aneurysm clipping was performed. Blood tests upon admission revealed high levels of free T3 and free T4 and low levels of thyroid-stimulating hormone. Upon determining that the patient had hyperthyroidism, thiamazole was administered. However, due to continuous impaired consciousness, fever, and persistence of tachycardia, the patient was diagnosed with thyroid storm. Oral potassium iodide and hydrocortisone were added to the treatment. The treatment was successful as the patient's symptoms improved, and she became lucid. In this case, we believe that in the presence of untreated hyperthyroidism, the onset of subarachnoid hemorrhage induced thyroid storm. Tachycardia of 130 bpm or higher, which is the diagnostic criterion for thyroid storm, rarely occurs with subarachnoid hemorrhage. Therefore, we believe it is an important factor for recognizing the presence of the thyroid storm. In this case, clipping surgery was prioritized which resulted in a favorable outcome. However, it is possible that invasive surgery may have exacerbated thyroid storm, suggesting that treatment should be tailored as per patient's condition. CONCLUSION: If a pulse rate of 130 bpm or higher is observed alongside subarachnoid hemorrhage, we recommend considering the possibility of concomitant thyroid storm and testing for thyroid hormone. If concomitant thyroid storm is present, we believe that a treatment plan tailored to the patient's condition is critical, and early diagnosis will lead to a favorable outcome for the patient.

Effect of a short video on patients' motivation for dose reduction or cessation of hypnotics.

Recently, addiction to regular doses of hypnotics has become a problem. While many patients report a desire to reduce their dosage, many do not agree with their physicians' suggestions for reduction. In this study, we created an online short video targeting patient motivation to reduce hypnotics usage and examined its efficacy and factors associated with the intention to reduce medication. We created a 10 min video that included "sleep education," "guidance for reducing the use of hypnotics," and "systematic motivation for reducing the use of hypnotics" and posted it on our website. For 1 year, we conducted a questionnaire survey to determine the effectiveness of the video and factors associated with the intention to reduce hypnotics use. Of 4548 viewers, 609 (13.4%) completed the questionnaire, 369 (67.9%) of whom used hypnotics. Most respondents were older adults. The intention to reduce medication use was significantly strengthened after watching the video in 37.7% of medication users (effect size 0.404). In the group that was not inclined toward medication reduction before viewing, 85.2% of patients had stronger intentions to reduce medication use after watching the video (effect size 0.818). "Memorable content about side effects" was extracted as a factor related to reinforcement of the intention to reduce medication use, suggesting that prescribing physicians' descriptions of current insomnia treatment is inadequate in explaining side effects to patients. A short informational video can have beneficial effects on patients' motivation for dose reduction or cessation of hypnotics. Supplementary Information: The online version contains supplementary material available at 10.1007/s41105-023-00446-4.

Prolonged mechanical ventilation in patients with severe COVID-19 is associated with serial modified-lung ultrasound scores: A single-centre cohort study.

Lung ultrasound (LUS), a rapid, bedside, goal-oriented diagnostic test, can be quantitatively assessed, and the scores can be used to evaluate disease progression. However, little data exists on predicting prolonged mechanical ventilation (PMV) and successful extubation using serial LUS scores. We examined the relationship of PMV with successful extubation in patients with severe coronavirus disease (COVID-19) by using two types of serial LUS scores. One LUS score evaluated both the pleura and lung fields, while the other assessed each separately (modified-LUS score). Both LUS scores were determined for 20 consecutive patients with severe COVID-19 at three timepoints: admission (day-1), after 48 h (day-3), and on the seventh follow-up day (day-7). We compared LUS scores with the radiographic assessment of the lung oedema (RALE) scores and laboratory test results, at the three timepoints. The PMV and successful extubation groups showed no significant differences in mortality, but significant differences occurred on day-3 and day-7 both LUS scores, day-7 RALE score, and day-7 PaO2/FiO2 ratio, in the PMV group (p<0.05); and day-3 and day-7 modified-LUS scores, day-7 C-reactive protein levels, and day-7 PaO2/FiO2 ratio, in the successful extubation group (p<0.05). The area under the curves (AUC) of LUS scores on day-3 and day-7, modified-LUS scores on day-3 and day-7,RALE score on day-7, and PaO2/FiO2 ratio on day-7 in the PMV group were 0.98, 0.85, 0.88, 0.98, 0.77, and 0.80, respectively. The AUC of modified-LUS scores on day-3 and day-7, C-reactive protein levels on day-7, and PaO2/FiO2 ratio on day-7 in the successful extubation group were 0.79, 0.90, 0.82, and 0.79, respectively. The modified-LUS score on day 7 was significantly higher than that on day 1 in PMV group (p<0.05). While the LUS score did not exhibit significant differences. The serial modified-LUS score of patients with severe COVID-19 could predict PMV.

Validating the trauma care system developed by Yokohama City local government.

Background: Since becoming the city with the first government-designated major trauma center in 2014, Yokohama has been striving to centralize care for extensive trauma patients. Hence, in this study, the Yokohama City Major Trauma Care Advisory Committee tested the efficacy of the centralization of care for trauma patients. Methods: This investigation included all cases of deaths due to road traffic accidents that occurred in the 2-year period following the establishment of the major trauma center. The probability of survival was calculated using data provided by the police and fire departments. Cases that died despite having a probability of survival of 50% or more were included in the survey undertaken by physicians recommended by the Japanese Association for the Surgery of Trauma, who visited the hospitals. Results: Of those surveyed, preventable trauma death accounted for 1 case (1.7%) and potentially preventable trauma death accounted for 7 (11.9%), compared with 5 (9.8%) and 11 (21%) cases, respectively, in the period 2009-2010. Conclusions: Comparing the survey conducted before establishment of the major trauma center, those results support the benefits of centralizing care for severe trauma cases. We aim to continue improving trauma care provided through the center along with the Yokohama Medical Control Council and to overcome challenges that were identified through the peer review.

Association between post-extubation upper airway obstruction symptoms and airway size measured by computed tomography: a single-center observational study.

BACKGROUND: Computed tomography (CT) is often performed to assess patients; however, little is known about how airway size measured by CT scan imaging might influence the occurrence of post-extubation upper airway obstruction. METHODS: This study aimed to evaluate the association between airway size measured by CT and the incidence of post-extubation upper airway obstruction symptoms for each sex. This single-center observational study was conducted at a tertiary emergency medical center/severe trauma center with a 12-bed intensive care unit. We enrolled consecutive adult patients (aged ≥ 20 years), who were intubated in the emergency room, between January 2016 and March 2019. Patients who underwent a CT scan of the glottic region within three hours before and after intubation were included in the analysis. For each sex, we first divided the patients into two groups: those who had post-extubation stridor, hoarseness, or both and those who had no such symptoms. Then, we compared the two groups using the Mann-Whitney U test and Fisher's exact test. Univariate and multivariate logistic regression analyses were also performed. RESULTS: During the 39 months, 855 patients were enrolled in this study. A total of 217 patients underwent CT of the glottic region within three hours before and after intubation. Five patients had no records of symptoms after extubation. Thus, we analyzed data from 212 patients. This study included 144 males and 68 females. In female patients, the median [inter-quartile range] (average) of the transverse diameter of the glottis/endotracheal tube outer diameter (OD) ratio was smaller in patients with post-extubation upper airway obstruction symptoms than in patients without the symptoms (1.00 [1.00-1.00] (0.9572) vs. 1.00 [1.00-1.00] (1.00296), respectively; p = .013). Multivariate logistic regression analysis showed that the glottis/tube OD ratio < 1 was associated with the symptoms in females (odds ratio: 95% confidence interval, 5.68: 1.04-30.97). There was no relation between the airway sizes and the symptoms in male patients. CONCLUSIONS: In female patients, no gap between the endotracheal tube and the vocal codes or the glottic transverse diameter being smaller than the endotracheal tube OD on CT scan was associated with post-extubation upper airway obstruction symptoms.

Detection of Iliopsoas Hematoma by Retrospective Radiography in Veno-Venous Extracorporeal Membrane Oxygenation for a COVID-19 Patient.

In coronavirus disease 2019 (COVID-19), veno-venous extracorporeal membrane oxygenation (VV-ECMO) is used to manage respiratory distress. This study's key clinical question was whether COVID-19 could be complicated by hemorrhagic and thrombotic events, such as iliopsoas hematoma (IPH), during the management of ECMO and the method to quickly and effectively detect IPH. A 52-year-old man with fever and dyspnea was diagnosed with COVID-19 pneumonia. He warranted VV-ECMO management on day 9, which was successfully tapered off on day 18. On day 20, computed tomography revealed a unilateral iliopsoas hematoma that was successfully managed with conservative care. However, a retrospective review of abdominal radiography performed on day 14 revealed a positive left psoas sign. When managing severe COVID-19 patients with VV-ECMO, cautious anticoagulative care and abdominal X-ray findings are warranted when considering the diagnosis of iliopsoas hematoma, including circulatory instability, anemia, and pain associated with limb movement.

Comparison of the effects of cognitive-behavioral therapy for insomnia between patients with primary insomnia and comorbid insomnia.

Cognitive behavioral therapy for insomnia (CBT-I) is effective for not only primary insomnia (PI) but also comorbid insomnia (CI; insomnia associated with psychiatric/physical diseases or other types of sleep disorders). This study aimed to compare the outcomes of CBT-I implemented in the same manner between patients with PI and CI. In total, 41 adult patients who had completed CBT-I were enrolled in this retrospective analysis and divided into a PI group and a CI group. The authors then examined and compared the significance of changes after therapy between the two groups. The magnitude of improvement on the Japanese version of the Insomnia Severity Index (ISI-J) was analyzed as the primary endpoint. In the PI group (n = 24), both the ISI-J score and the dose of hypnotics decreased significantly following CBT-I. On the other hand, in the CI group (n = 17), only the dose of hypnotics decreased significantly; no statistically significant improvement was seen in the ISI-J score. Sleep onset latency and sleep quality rating in recorded sleep diaries were significantly correlated with improved ISI-J scores in the CI group only. CBT-I was shown to be effective for CI, but its efficacy for CI was inferior to that for PI in terms of impact on sleep and mental condition. These results suggest that in addition to the basic components of CBT-I, treatment for CI, especially when accompanied by severe insomnia symptoms, should include approaches targeting the comorbid disease.

Combining IL-6 and SARS-CoV-2 RNAaemia-based risk stratification for fatal outcomes of COVID-19.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic rapidly increases the use of mechanical ventilation (MV). Such cases further require extracorporeal membrane oxygenation (ECMO) and have a high mortality. OBJECTIVE: We aimed to identify prognostic biomarkers pathophysiologically reflecting future deterioration of COVID-19. METHODS: Clinical, laboratory, and outcome data were collected from 102 patients with moderate to severe COVID-19. Interleukin (IL)-6 level and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA copy number in plasma were assessed with ELISA kit and quantitative PCR. RESULTS: Twelve patients died or required ECMO owing to acute respiratory distress syndrome despite the use of MV. Among various variables, a ratio of oxygen saturation to fraction of inspired oxygen (SpO2/FiO2), IL-6, and SARS-CoV-2 RNA on admission before intubation were strongly predictive of fatal outcomes after the MV use. Moreover, among these variables, combining SpO2/FiO2, IL-6, and SARS-CoV-2 RNA showed the highest accuracy (area under the curve: 0.934). In patients with low SpO2/FiO2 (< 261), fatal event-rate after the MV use at the 30-day was significantly higher in patients with high IL-6 (> 49 pg/mL) and SARS-CoV-2 RNAaemia (> 1.5 copies/µL) compared to those with high IL-6 or RNAaemia or without high IL-6 and RNAaemia (88% vs. 22% or 8%, log-rank test P = 0.0097 or P < 0.0001, respectively). CONCLUSIONS: Combining SpO2/FiO2 with high IL-6 and SARS-CoV-2 RNAaemia which reflect hyperinflammation and viral overload allows accurately and before intubation identifying COVID-19 patients at high risk for ECMO use or in-hospital death despite the use of MV.

Temporal change in Syndecan-1 as a therapeutic target and a biomarker for the severity classification of COVID-19.

BACKGROUND: Coronavirus disease 2019 (COVID-19) pneumonitis associated with severe respiratory failure is associated with high mortality. The pathogenesis of COVID-19 is associated with microembolism or microvascular endothelial injuries. Here, we report that syndecan-1 (SDC-1), a component of the endothelial glycocalyx, may be a biomarker of severity classification for COVID-19 related to endothelial injury. METHODS AND ANALYSIS: We analyzed the data of COVID-19 patients for 1 year from February 2020 at Yokohama City University Hospital and Yokohama City University Medical Center Hospital. We selected COVID-19 patients who required admission care, including intensive care, and analyzed the classification of severe and critical COVID-19 retrospectively, using various clinical data and laboratory data with SDC-1 by ELISA. RESULTS: We analyzed clinical and laboratory data with SDC-1 in five severe COVID-19 and ten critical COVID-19 patients. In the two groups, their backgrounds were almost the same. In laboratory data, the LDH, CHE, and CRP levels showed significant differences in each group (P = 0.032, P < 0.0001, and P = 0.007, respectively) with no significant differences in coagulation-related factors (platelet, PT-INR, d-dimer, ISTH score; P = 0.200, 0.277, 0.655, and 0.36, respectively). For the clinical data, the SOFA score was significantly different from admission day to day 14 of admission (p < 0.0001). The SDC-1 levels of critical COVID-19 patients were significantly higher on admission day and all-time course compared with the levels of severe COVID-19 patients (P = 0.009 and P < 0.0001, respectively). CONCLUSIONS: Temporal change of SDC-1 levels closely reflect the severity of COVID-19, therefore, SDC-1 may be a therapeutic target and a biomarker for the severity classification of Covid-19.

Usefulness of serial lung ultrasound for a severe COVID-19 patient on extracorporeal membrane oxygenation.

Computed tomography (CT) is the most reliable method to evaluate the progression of COVID-19 pneumonitis. However, in a pandemic, transportation of critically ill invasively ventilated patients to radiology facilities is challenging, especially for those on extracorporeal membrane oxygenation (ECMO). Notably, lung ultrasound (LUS) is a favored alternative imaging modality due to its ease of use at the point of care, which reduces the infectious risk of exposure and transmission; repeatability; absence of radiation exposure; and low cost. We demonstrated that serial LUS compares favorably with other imaging modalities in terms of usefulness for evaluating lung aeration and recovery in an ECMO-managed COVID-19 patient.

Risk factors associated with symptoms of post-extubation upper airway obstruction in the emergency setting.

OBJECTIVE: Post-extubation stridor and hoarseness are important clinical manifestations that indicate laryngeal edema due to intubation. In previous studies the incidence of post-extubation stridor and hoarseness ranged from 1.5% to 26.3% in postoperative patients and patients in the intensive care unit. Female sex and prolonged intubation are reportedly risk factors for post-extubation stridor. However, the risk factors for post-extubation stridor and the appropriate endotracheal tube size in emergency settings remain unknown. This study was performed to identify the risk factors for post-extubation laryngeal edema after emergency intubation. METHODS: A prospective observational study was conducted in a tertiary emergency medical center/trauma center. The primary outcome was post-extubation stridor and hoarseness. RESULTS: During the study period, 482 emergency intubations and 227 extubations were performed in adult patients. In total, 29% of the patients presented symptoms of stridor and/or hoarseness. Female sex (odds ratio, 2.65; 95% confidence interval, 1.21-5.81) and the duration of intubation (odds ratio, 1.18; 95% confidence interval, 1.05-1.32) were associated with stridor and/or hoarseness. CONCLUSIONS: Patients who undergo emergency intubation have a higher risk of post-extubation upper airway obstruction symptoms than postoperative patients and patients in the intensive care unit, and female sex is associated with these symptoms.

Veno-venous extracorporeal membrane oxygenation for severe pneumonia: COVID-19 case in Japan.

BACKGROUND: Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is one of the ultimate treatments for acute respiratory failure. However, the effectiveness of ECMO in patients with novel coronavirus disease (COVID-19) is unknown. CASE PRESENTATION: A 72-year-old woman who was a passenger of a cruise ship tested positive for the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) while in quarantine on board using throat swab. Three days after admission, her condition deteriorated, and she was subsequently intubated. On day 6, VV-ECMO was introduced. Lopinavir/ritonavir was given; continuous renal replacement therapy was also introduced. On day 10, her chest radiography and lung compliance improved. She was weaned off ECMO on day 12. CONCLUSION: Treatment of severe pneumonia in COVID-19 by ECMO should recognize lung plasticity considering time to ECMO introduction and interstitial biomarkers. In Japan, centralization of ECMO patients has not been sufficient. Thus, we suggest nationwide centralization and further research to respond to the crisis caused by COVID-19.

A case report: Veno-venous extracorporeal membrane oxygenation for severe blunt thoracic trauma.

INTRODUCTION: The use of veno-venous extracorporeal membrane oxygenation (VV-ECMO) in trauma patients has been controversial, but VV-ECMO plays a crucial role when the lungs are extensively damaged and when conventional management has failed. VV-ECMO provides adequate tissue oxygenation and an opportunity for lung recovery. However, VV-ECMO remains contraindicated in patients with a risk of bleeding because of systemic anticoagulation during the treatment. The most important point is controlling the bleeding from severe trauma. CASE: A 32-year-old male experienced blunt trauma due to a traffic accident. He presented with bilateral hemopneumothorax and bilateral flail chest. We performed emergency thoracotomy for active bleeding and established circulatory stability. After surgery, the oxygenation deteriorated under mechanical ventilation, so we decided to establish VV-ECMO. However, bleeding from the bilateral lung contusions increased after VV-ECMO was established, and the patient was switched to heparin-free ECMO. After conversion, we could control the bronchial bleeding, especially the lung hematomas, and the oxygenation recovered. The patient was discharged without significant complications. VV-ECMO and mechanical ventilation were stopped on days 10 and 11, respectively. He was discharged from the ICU on day 15. CONCLUSION: When we consider the use of ECMO for patients with uncontrollable, severe bleeding caused by blunt trauma, it may be necessary to use a higher flow setting for heparin-free ECMO than typically used for patients without trauma to prevent thrombosis.

Treating patients in a trauma room equipped with computed tomography and patients' mortality: a non-controlled comparison study.

Background: To improve acute trauma care workflow, the number of trauma centers equipped with a computed tomography (CT) machine in the trauma resuscitation room has increased. The effect of the presence of a CT machine in the trauma room on a patient's outcome is still unclear. This study evaluated the association between a CT machine in the trauma room and a patient's outcome. Methods: Our study included all trauma patients admitted to a trauma center in Yokohama, Japan, between April 2014 and March 2016. We compared 140 patients treated using a conventional resuscitation room with 106 patients treated in new trauma rooms equipped with a CT machine. Results: For the group treated in a trauma room with a CT machine, the Injury Severity Score (13.0 vs. 9.0; p = 0.002), CT scans of the head (78.3 vs. 66.4%; p = 0.046), CT scans of the body trunk (75.5 vs. 58.6%; p = 0.007), intubation in the emergency department (48.1 vs. 30.7%; p = 0.008), and multiple trauma patients (47.2 vs. 30.0%; p = 0.008) were significantly higher and Trauma and Injury Severity Score probability of survival (96.75 vs. 97.80; p = 0.009) was significantly lower than the group treated in a conventional resuscitation room. In multivariate analysis and propensity score matched analysis, being treated in a trauma room with a CT machine was an independent predictor for fewer hospital deaths (odds ratio 0.002; 95% CI 0.00-0.75; p = 0.04, and 0.07; 0.00-0.98, respectively). Conclusions: Equipping a trauma room with a CT machine reduced the time in decision-making for treating a trauma patient and subsequently lowered the mortality of trauma patients.

Human herpesvirus 6 and 7 are biomarkers for fatigue, which distinguish between physiological fatigue and pathological fatigue.

Fatigue reduces productivity and is a risk factor for lifestyle diseases and mental disorders. Everyone experiences physiological fatigue and recovers with rest. Pathological fatigue, however, greatly reduces quality of life and requires therapeutic interventions. It is therefore necessary to distinguish between the two but there has been no biomarker for this. We report on the measurement of salivary human herpesvirus (HHV-) 6 and HHV-7 as biomarkers for quantifying physiological fatigue. They increased with military training and work and rapidly decreased with rest. Our results suggested that macrophage activation and differentiation were necessary for virus reactivation. However, HHV-6 and HHV-7 did not increase in obstructive sleep apnea syndrome (OSAS), chronic fatigue syndrome (CFS) and major depressive disorder (MDD), which are thought to cause pathological fatigue. Thus, HHV-6 and HHV-7 would be useful biomarkers for distinguishing between physiological and pathological fatigue. Our findings suggest a fundamentally new approach to evaluating fatigue and preventing fatigue-related diseases.

Risky locations for out-of-hospital cardiopulmonary arrest in a typical urban city.

BACKGROUND: The aim of this study is to clarify the circumstances including the locations where critical events resulting in out-of-hospital cardiopulmonary arrest (OHCPA) occur. MATERIALS AND METHODS: Subjects of this population-based observational case series study were the clinical records of patients with nontraumatic and nonneck-hanging OHCPA. RESULTS: Of all 1546 cases, 10.3% occurred in a public place (shop, restaurant, workplace, stations, public house, sports venue, and bus), 8.3% on the street, 73.4% in a private location (victim's home, the homes of the victims' relatives or friends or cheap bedrooms, where poor homeless people live), and 4.1% in residential institutions. In OHCPA occurring in private locations, the frequency of asystole was higher and the outcome was poorer than in other locations. A total of 181 OHCPA cases (11.7%) took place in the lavatory and 166 (10.7%) in the bathroom; of these, only 7 (3.9% of OHCPA in the lavatory) and none in the bath room achieved good outcomes. The frequencies of shockable initial rhythm occurring in the lavatory and in bath room were 3.7% and 1.1% (lower than in other locations, P = 0.011 and 0.002), and cardiac etiology in OHCPA occurring in these locations were 46.7% and 78.4% (the latter higher than in other locations, P < 0.001). CONCLUSIONS: An unignorable population suffered from OHCPA in private locations, particularly in the lavatory and bathroom; their initial rhythm was usually asystole and their outcomes were poor, despite the high frequency of cardiac etiology in the bathroom. We should try to treat OHCPA victims and to prevent occurrence of OHCPA in these risky spaces by considering their specific conditions.

Comparisons of short-term efficacy between individual and group cognitive behavioral therapy for primary insomnia.

The purpose of this study was to compare the efficacy of individual and group cognitive behavioral therapy for insomnia (CBT-I) in outpatients with primary insomnia diagnosed by DSM-IV-TR. The participants were 20 individually treated (I-CBT-I) and 25 treated in a group therapy format (three to five patients per group) (G-CBT-I), which showed no significant difference regarding demographic variables between groups. The same components of CBT-I stimulus control therapy, sleep restriction therapy, cognitive therapy, and sleep hygiene education were applied on both groups. The short-term outcome (4 weeks after treatment) was measured by sleep logs, actigraphy, the Pittsburgh Sleep Quality Index (PSQI), and the Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS), and was compared between I-CBT-I and G-CBT-I. The results indicated that CBT-I was effective in improving subjective and objective sleep parameters and subjective sleep evaluations for both individual and group treatment. However, I-CBT-I resulted in significantly better improvements over G-CBT-I, in (i) objective and subjective sleep onset latency time, (ii) objective sleep efficacy and moving time during sleeping, (iii) overall sleep quality and duration of actual sleep time in PSQI, (iv) consequences of insomnia, control and predictability of sleep, sleep requirement expectation, and sleep-promoting practices in DBAS. The present study suggested the superiority of I-CBT-I over G-CBT-I in clinical settings, and further evaluations are necessary.