Hyperdry Human Amniotic Membrane as a Protective Dressing for Open Wounds With Exposed Bowel in Mice.

INTRODUCTION: An enteroatmospheric fistula forms when the exposed bowel is perforated with chronic enteric fistula formation. Currently, there is no established preventative method for this condition. Hyperdry (HD) amniotic membrane (AM) can promote early granulation tissue formation on the exposed viscera and is suitable for dressing intractable wounds as it possesses anti-inflammatory, antibacterial, and immunomodulatory properties. This study investigated whether HD-AM promotes early formation of blood vessel-containing granulation tissue for enteroatmospheric fistula treatment. METHODS: An experimental animal model of an open wound with exposed bowel was developed. A 15 × 20 mm wound was prepared on the abdomen of Institute of Cancer Research mice, and the HD-AM was placed. The mice were assigned to one of the following groups: HD-AM group, in which the stromal layer of the HD-AM was placed in contact with the exposed bowel; HD-AM UD group, in which the epithelial layer of the HD-AM was placed in contact with the exposed bowel; and the HD-AM (-) or control group, in which the HD-AM was not used. RESULTS: On postoperative days 7 and 14, granulation tissue thickness significantly increased in the HD-AM and HD-AM UD groups compared with that in the HD-AM (-) group. Macrophages accumulated in the HD-AM epithelium only in the HD-AM group. During HD-AM contact, a subset of invading macrophages switched from M1 to M2 phenotype. CONCLUSIONS: HD-AM is a practical wound dressing with its scaffolding function, regulation of TGF ß-1 and C-X-C motif chemokine 5 (CXCL-5), and ability to induce M1-to-M2 macrophage conversion.

Describing and Quantifying Wrong-Patient Medication Errors Through a Study of Incident Reports.

Purpose: Our aim was to inform a new definition of wrong-patient errors, obtained through an analysis of incident reports related to medication errors. Methods: We investigated wrong-patient medication errors in incident reports voluntarily reported by medical staff using a web-based incident reporting system from 2015 to 2016 at a university hospital in Japan. Incident report content was separately evaluated by four evaluators using investigational methods for clinical incidents from the Clinical Risk Unit and the Association of Litigation and Risk Management. They investigated whether it was the patient or drug that was incorrectly chosen during wrong-patient errors in drug administration in incident reports and assessed contributory factors which affected the error occurrence. The evaluators integrated the results and interpreted them together. Results: Out of a total 4337 IRs, only 30 cases (2%) contained wrong-patient errors in medication administration. The cases where the intended drugs were administered to incorrect patients occurred less frequently than cases where the wrong drugs were administered to the intended patients through the investigation of wrong targets. After a discussion, the evaluators concluded that the patient - drug/CPOE screen mismatch, caused by choosing the wrong patient, drug, or CPOE screen (mix-ups), occurred in the wrong-patient medication errors. These errors were caused by three conditions: (1) where two patients/drugs were listed next to one another, (2) where two patients' last names/drugs' names were the same, and (3) where the patient/drug/CPOE screen in front of the staff involved was believed to be the correct one. Additionally, these errors also involved insufficient confirmation, which led to failure to detect and correct the mismatch occurrences. Conclusion: Based on our study, we propose a new definition of wrong-patient medication errors: they consisted of choosing a wrong target and insufficient confirmation. We will investigate other types of wrong-patient errors to apply this definition.

Distribution of amniotic stem cells in human term amnion membrane.

Amnion membrane studies related to miscarriage have been conducted in the field of obstetrics and gynecology. However, the distribution of stem cells within the amnion and the differences in the properties of each type of stem cells are still not well understood. We address this gap in knowledge in the present study where we morphologically classified the amnion membrane, and we clarified the distribution of stem cells here to identify functionally different amniotic membrane-derived stem cells. The amnion can be divided into a site that is continuous with the umbilical cord (region A), a site that adheres to the placenta (region B), and a site that is located opposite the placenta (region C). We found that human amnion epithelial stem cells (HAECs) that strongly express stem cell markers were abundant in area A. HAEC not only expressesed stem cell-specific surface markers TRA-1-60, Tra-1-81, SSEA4, SSEA3, but was also OCT-3/4 positive and had alkaline phosphatase activity. Human amniotic mesenchymal stem cells expressed KLF-A, OCTA, Oct3/4, c-MYC and Sox2 which is transcription factor. Especially, in regions A and B they have expressed CD73, and the higher expression of BCRP which is drug excretion transporter protein than the other parts. These data suggest that different types of stem cells may have existed in different area. The understanding the relation with characteristics of the stem cells in each area and function would allow for the efficient harvest of suitable HAE and HAM stem cells as using tool for regenerative medicine.

Effect of Advanced Airway Management by Paramedics During Out-of-Hospital Cardiac Arrest on Chest Compression Fraction and Return of Spontaneous Circulation.

PURPOSE: To obtain effective systemic blood flow and coronary perfusion by chest compressions during cardiopulmonary resuscitation, it is recommended that the interruption time of chest compressions be kept to a minimum, and that the chest compression fraction (CCF) should be kept high. In this study, we examined the effects of advanced airway management by paramedics in out-of-hospital cardiac arrest (OHCA) cases on CCF and on return of spontaneous circulation (ROSC) before arrival at the hospital. PARTICIPANTS AND METHODS: A total of 283 adult, non-traumatic OHCA cases who were in cardiopulmonary arrest at the time of EMS contact between April 2015 and March 2017 were registered for this study. We retrospectively investigated the presence or absence of advanced airway clearance, CCF and ROSC during CPR. CCF was calculated by measuring the chest compression interruption time from the ECG waveform recorded on a semiautomatic defibrillator (Philips HeartStart MRX). The data obtained were recorded on a computer, and comparisons between groups were examined using an untested t-test and χ2- test. RESULTS: Of the 283 patients with OHCA, 159 were included in the analysis. The CCF of the AAM group was 89.4%, which was significantly higher than that in the BMV group (84.3%) (P<0.01). Forty-one patients had ROSC at the time of arrival at the hospital, and the CCF of ROSC patients was 89.7%, which was significantly higher than that of non-ROSC patients (87.2%) (P<0.01). ROSC was also obtained in 31.8% of the patients in the AAM group, which was significantly higher than that in the BMV group (12.2%). CONCLUSION: In this study, we found that advanced airway management during prehospital emergency transport by paramedics showed high CCF and ROSC rates and contributed to improving the prognosis of OHCA patients through high-quality resuscitation.

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.

Efficacy of an educational program for medical staff in preventing incidents related to Foley catheter insertion and maintenance: A single-institution retrospective study.

OBJECTIVES: To analyze incidents related to Foley catheter insertion and maintenance, and to compare the rate of incidents before and after a medical staff education program. METHODS: Data regarding Foley catheter insertion incidents and maintenance were collected at Toyama University Hospital, Toyama, Japan. The degree of harm for each incident was assessed. In the middle of the study period, a medical staff education program by urologists was implemented to help understand basic urological anatomy, urethral catheter insertion techniques and catheter safety. The incidents before and after the intervention were then compared. RESULTS: During the study period, Foley catheter insertion was carried out in 12 476 patients. Related incidents were reported in 66 (0.53%), including 22 (0.18%) occurring during catheter insertion and 44 (0.35%) occurring during catheter maintenance. A total of 13 (0.10%) cases of urethral injury were reported. The degree of harm associated with catheter insertion incidents was moderate in 13. Nine of these incidents occurred before the education program (9/6799, 0.13%), and four were reported after the end of the program (4/5677, 0.07%, P = 0.4303). Transient suprapubic cystostomy was required in two due to urethral injury reported before the program. Among 44 incidents occurring during catheter maintenance, 37 catheters were removed or cut by the patient. Such incidents occurred regardless of the education program. CONCLUSIONS: The rate of incidents related to Foley catheter use at our institution is low. A specific medical staff education program might prevent iatrogenic catheter-related urethral injury requiring cystostomy.

Monitoring of viral load by RT-PCR caused decision making to continue ECMO therapy for a patient with COVID-19.

Most patients with coronavirus disease 2019 (COVID-19) have just only mild symptoms, but about 5% are very severe. Although extracorporeal membranous oxygenation (ECMO) is sometimes used in critically patients with COVID-19, ECMO is only an adjunct, not the main treatment. If the patient's condition deteriorates and it is determined to be irreversible, it is necessary to decide to stop ECMO. A 54-year-old man was admitted on day 6 of onset with a chief complaint of high fever and cough. Computed tomography (CT) showed a ground glass opacity in both lungs, and reverse transcription-polymerase chain reaction (RT-PCR) diagnosed COVID-19. He was admitted to the hospital and started to receive oxygen and favipiravir. After that, his respiratory condition deteriorated, and he was intubated and ventilated on day 9 of onset, and ECMO was introduced on day 12. Two days after the introduction of ECMO, C-reactive protein (CRP) increased, chest X-p showed no improvement in pneumonia, and PaO2/FiO2 decreased again. As D-dimer rose and found a blood clot in the ECMO circuit, we had to decide whether to replace the circuit and continue with ECMO or stop ECMO. At this time, the viral load by RT-PCR was drastically reduced to about 1/1750. We decided to continue ECMO therapy and replaced the circuit. The patient's respiratory status subsequently improved and ECMO was stopped on day 21 of onset. In conclusion, viral load measurement by RT-PCR may be one of the indicators for promoting the treatment of severe COVID-19 patients.

Hyperdry human amniotic membrane application as a wound dressing for a full-thickness skin excision after a third-degree burn injury.

BACKGROUND: Severe burn injuries create large skin defects that render the host susceptible to bacterial infections. Burn wound infection often causes systemic sepsis and severe septicemia, resulting in an increase in the mortality of patients with severe burn injuries. Therefore, appropriate wound care is important to prevent infection and improve patient outcomes. However, it is difficult to heal a third-degree burn injury. The aim of this study was to investigate whether hyperdry human amniotic membrane (HD-AM) could promote early granulation tissue formation after full-thickness skin excision in third-degree burn injury sites in mice. METHODS: After the development of HD-AM and creation of a third-degree burn injury model, the HD-AM was either placed or not placed on the wound area in the HD-AM group or HD-AM group, respectively. The groups were prepared for evaluation on postoperative days 1, 4 and 7. Azan staining was used for granulation tissue evaluation, and estimation of CD163, transforming growth factor beta-1 (TGF-ß1), vascular endothelial growth factor (VEGF), CD31, alpha-smooth muscle actin (α-SMA) and Iba1 expression was performed by immunohistochemical staining. Quantitative reverse-transcription polymerase chain reaction (PCR) was used to investigate gene expression of growth factors, cell migration chemokines and angiogenic and inflammatory markers. RESULTS: The HD-AM group showed significant early and qualitatively good growth of granulation tissue on the full-thickness skin excision site. HD-AM promoted early-phase inflammatory cell infiltration, fibroblast migration and angiogenesis in the granulation tissue. Additionally, the early infiltration of cells of the immune system was observed. CONCLUSIONS: HD-AM may be useful as a new wound dressing material for full-thickness skin excision sites after third-degree burn injuries, and may be a new therapeutic technique for improving the survival rate of patients with severe burn injuries.

Impact of outpatient pharmacy interventions on management of thyroid patients receiving lenvatinib.

OBJECTIVES: Medical oncologists and pharmacists at our institution established an integrated support program aimed at preventing unnecessary treatment interruption or dose reduction during oral targeted therapy with lenvatinib. Here, we evaluated the benefits of this program in managing patients with thyroid cancer receiving lenvatinib. METHODS: We retrospectively evaluated thyroid cancer patients who received lenvatinib between May 2015 and March 2017. This descriptive study collected records in which pharmacists contributed to changing doctors' prescriptions and categorized the interventions. RESULTS: During the study period, 24 thyroid cancer patients were treated with lenvatinib. Among patients, the incidence of temporary interruption and dose reduction of lenvatinib due to adverse drug reactions was 100% (n = 24) and 83.3% (n = 20), respectively. There were 193 temporary interruptions of lenvatinib due to adverse drug reactions. A total of 501 outpatient pharmacy services were conducted by pharmacists in collaboration with oncologists, of which 125 were interventions (24.9%). In addition, pharmacists conducted 156 telephone follow-up services; 18 (11.5%) of these were to consult an oncologist about a patient's confirmed problems and resulted in the decision to continue observation with no medical intervention while 41 (26.2%) resulted in the oncologist deciding to temporarily interrupt lenvatinib treatment after the report of an adverse drug reaction from the pharmacist. CONCLUSION: Pharmacist interventions in collaboration with medical oncologists improved lenvatinib therapy. Interventions for outpatients were conducted not only in outpatient clinics but also by telephone follow-up, clarifying the importance of continuous management for patients at risk of adverse reactions and misuse of oral medicine.

A half-day stroke workshop based on the Kirkpatrick model to improve new clinical staff behavior.

INTRODUCTION: The present study aimed to determine the validity and usefulness of scales and training programs for clinical staff to evaluate nerve signs as an initial response to stroke. We developed a stroke workshop, using the analysis, design, development, implementation, and evaluation (ADDIE) model method based on instructional systems design theory. METHODS: The workshop aimed to improve the basic first aid skills of clinical staff for stroke. The participants (n=46) were randomly assigned to conventional Cincinnati Pre-hospital Stroke Scale (CPSS) or modified CPSS groups (simple randomization). Short-term case simulation was conducted immediately after the training as well as 6 months later to evaluate the nurses' skills. We conducted evaluations, using an instructional framework throughout the ADDIE process. We used the Kirkpatrick model to evaluate the educational effect of up to level 3 in this study. The Wilcoxon signed-rank test was used to analyze differences between the pre-test and post-test groups. RESULTS: The evaluation of the new clinical staff stroke emergency training program, either using the conventional CPSS or the modified CPSS, showed that the participants were highly satisfied and exhibited improved knowledge and skills (conventional CPSS: 3.05 ± 0.73 vs 3.64 ± 0.59, P = 0.012 and modified CPSS: 2.95 ± 0.97 vs 3.61 ± 0.49, P = 0.111, before training vs after training, respectively). On the other hand, it was difficult for the participants to evaluate neurologic conditions using the modified CPSS compared with the conventional CPSS. CONCLUSION: These results demonstrated that stroke care training is effective in reaction, learning, and behavior. The modified CPSS could be useful as with the conventional CPSS. In future, evaluation of neurological conditions should be improved.

Importance of Continuing Education for Medical Staff to Improve the Confirmation Rate of Intent for Organ Donation.

BACKGROUND: Among Organisation for Economic Co-operation and Development countries, the number of cadaveric donors per population is the lowest in Japan. The present study investigated whether a continuing educational intervention for medical staff, such as Donor Action Program (DAP) that is aimed at increasing the number of cadaveric donors, improved the confirmation rate of organ donation in potential donors. MATERIAL AND METHODS: We studied 2 hospitals with emergency centers in Toyama, Japan. DAP was conducted 2 to 3 times each year. We extracted mortality cases recorded in the emergency care departments of each hospital for over 10 years between 2007, prior to DAP's implementation, and 2017 to examine the confirmation rate of the intent of the families of potential donors for organ donation and the timing and methods for confirming intent to donate in cases that resulted in organ donation. RESULTS: The confirmation rate increased after the introduction of DAP and remained high (over 80%) in both hospitals after 2012. Regarding actual organ donation, some patients were asked by staff about their intent when they became potential donors in addition to the hospitalization intake form; it was offered by family members of some of the patients. CONCLUSION: Regular educational training on organ donation improved the confirmation rate of potential organ donors' donation intention. For organ donation, medical practitioners must take the appropriate steps to confirm the patient's intent to donate when he/she is determined as a potential donor.

Clinical features of patients who died within 24 h after admission to a stroke care center.

Objective In Japan, stroke care is provided through medical cooperation and standardized treatment. However, various factors affect mortality in the hyperacute phase. The present study investigated factors associated with death within 24 h after admission for acute stroke. Methods Among 2335 patients admitted within 24 h after stroke onset from 1 January 2007 to 31 December 2012, a total of 139 deaths occurred. Forty-eight deaths occurred within 24 h after admission. We retrospectively examined the clinical features of these 48 patients. Results The overall mortality rate was 6.0%. When the initial 72-h period was divided into ≤24 h (Period I), >24 to 48 h (Period II), and >48 to 72 h (Period III), deaths were significantly more frequent in Period I than in the other two periods. The frequency of intracerebral haemorrhage (ICH) was also significantly higher in Period I than in the other two periods. Factors significantly associated with death from ICH were systolic blood pressure, hematoma volume, and surgery. Conclusion The mortality rate was low among patients with stroke transported to the authors' medical center within 24 h of onset. Blood pressure management and the timing of determining indications for surgery are important factors in acute haemorrhagic stroke care.

[Nonconvulsive status epilepticus in neurological emergencies].

According to the 2010 neuroresuscitation guideline, status epilepticus (SE) is a critical condition that causes respiratory and circulation dysfunction, including "acute consciousness disturbance" and "elevated intracranial pressure." There are two types of SE: general convulsive SE (GCSE) and nonconvulsive SE (NCSE). GCSE is easily diagnosed because the patients show continuous convulsions. In contrast, NCSE can only be diagnosed by electroencephalography (EEG), which can delay diagnosis. Moreover, GCSE and NCSE occasionally manifest in the same patient and alternate. Here, we describe the case of a 64-year-old male patient who experienced losses of consciousness mimicking stroke. We could not diagnose these episodes as NCSE until the patient had a general continuous convulsion. In this case, the delayed diagnosis of NCSE resulted in uncontrollable GCSE that required intensive management, including mechanical ventilation under sedation. It is important to recognize that NCSE can cause consciousness disturbance and to initiate treatment as soon as possible to improve patient prognosis. This could be achieved by performing an EEG earlier, such as at the scene of emergencies.

[Immediate Stroke Life Support: training for neuroresuscitation team in ER].

Immediate Stroke Life Support (ISLS) is a curriculum for evaluation and management of acute stroke syndromes. ISLS was developed by Japan ISLS task force consisting of Japanese Association of Acute Medicine (JAAM) and Japanese Congress on Neurological Emergencies (JCNE). The course incorporates role play, mannequin simulation modalities, and clinical maps. ISLS has undergone a collaborative iterative process from Japanese to enable English language / North American student participation. ISLS complements the neurological skills and knowledge which are essential to cerebral resuscitation. This program will introduce teachers to the techniques used in this course, through sequential train-the-trainer exercises in each of the integrated simulation techniques.

Report on the international Primary Neurosurgical Life Support course in the eighth Asian Congress of Neurological Surgeons in Kuala Lumpur, Malaysia.

On November 22, 2010, a simulation-based hands-on education course for medical staff in the neurosurgical fields was held in 8(th) Asian Congress of Neurological Surgeons (ACNS) in Kuala Lumpur, Malaysia. The present education course called Primary Neurosurgical Life Support (PNLS) course had been started by the Japan Society of Neurosurgical Emergency since 2008. This report summarizes the international version of PNLS course in 8(th) ACNS.

[Immediate Cardiac Life Support (ICLS) course developed by Japanese Association for Acute Medicine].

The Immediate Cardiac Life Support (ICLS) course was developed and launched by Japanese Association for Acute Medicine (JAAM) for resident training, in April 2002. The ICLS course is designed as multi-professional one-day (8 hours) resuscitation course and teaches the essential skills and team dynamics required to manage a patient in cardiac arrest for 10 minutes before the arrival of a cardiovascular specialist. The course consists of skill stations and scenario stations. The skill stations provide basic life support (BLS) with automated external defibrillator (AED), basic airway management and in-hospital management with electrocardiographic (ECG) monitoring with manual external defibrillator. In total, 117,246 candidates attended 6,971 ICLS courses until the end of December 2010. Furthermore, we developed additional course of ICLS to manage stroke, Immediate Stroke Life Support (ISLS). We also describe the development and structure of, and rationale for the ICLS course.

A simple and useful coma scale for patients with neurologic emergencies: the Emergency Coma Scale.

OBJECTIVES: The Emergency Coma Scale (ECS) was developed in Japan in 2003. We planned a multicenter study to evaluate the utility of the ECS by comparison of the ECS and the Glasgow Coma Scale (GCS). METHODS: Ten medical facilities, including 4 university hospitals in Japan, participated in this study. We evaluated and recorded the level of consciousness, using the ECS and GCS, of all patients transported to these medical facilities by ambulance. We then performed a statistical analysis of the level of rater agreement of each scale using the average weighted κ coefficient according to the types of diagnosis at time of discharge and the occupations of the raters. We then evaluated the relationship between outcome of patients and their scores on the ECS and GCS by logistic regression analysis. RESULTS: The ECS showed the greater agreement among raters in patient scoring (0.802). In patients with traumatic brain injury and cerebrovascular disease, the ECS also yielded the higher agreement (0.846 and 0.779, respectively). The ECS score appears to be more strongly related than the GCS to patient outcome as measured by the Glasgow Outcome Scale (GOS). CONCLUSIONS: Our results showed that the ECS is a simple and readily understandable coma scale for a wide range of professionals in the field of neurologic emergencies. Furthermore, ECS appears to be suitable for evaluating patients in neurologic emergency settings.

The Modules for ISLS/PNLS Combined Course as International Version: Report of Workshop in 9 International Conference of Cerebrovascular Surgery.

In Japan, there are two simulation based training systems for neurosurgical diseases, that are ISLS (Immediate Stroke Life Support) and PNLS (Primary Neurosurgical Life Support). Workshop on "First ISLS International Version Trial Task Force" came to a successful conclusion on November 12, 2009, in Nagoya, Japan. More than 30 international participants attended this workshop, organized by the Department of Neurosurgery, Fujita Health University. This report summarizes the modules for ISLS/PSLS combined course as international version from the workshop.