The Experience and the Characteristics of Patients With Tele-ICU Implementation in a Rural Community Hospital.

Background Tele-ICUs are increasingly being used in the US. In Japan, young physicians mainly operate rural community hospitals to manage severely ill patients. However, the introduction of the tele-ICU system in Japan is still uncommon. We introduced a tele-ICU system to a community hospital. The objective of this study is to determine if the newly introduced tele-ICU system is being effectively utilized. Methods This is a single-center, retrospective observational study. We introduced the tele-ICU system to the NachiKatsuura Town Onsen Hospital, Japan, in 2019. Thereafter, we retrospectively explored the characteristics of the consulted cases, the time of consultation, the Sequential Organ Failure Assessment (SOFA) score, and the number of consultations by month from 1st July 2019 to 31st March 2020. The main outcome was the monthly number of consultations, and other measures included the clinical characteristics of the consulted cases. Results A total of 81 cases were referred to the tele-ICU system within nine months. Sixty-two cases, excluding those with missing data, were included in the analysis. The number of consultations was almost constant during the study period and was most frequent during the day. The recommendations from tele-ICU physicians were mostly "advice on the treatment plan." The mean SOFA score was 2.56. Conclusions We introduced a Japanese-type tele-ICU system for Japanese rural community hospitals. Many cases from rural community hospitals that were referred to the tele-ICU systems were moderately severe and did not require urgent transportation. These cases are not indicated for emergency transportation and should be treated in rural community hospitals.

Super Formula for Diagnosing Disseminated Intravascular Coagulation Using Soluble C-Type Lectin-like Receptor 2.

The scoring systems for disseminated intravascular coagulation (DIC) criteria require several adequate cutoff values, vary, and are complicated. Accordingly, a simpler and quicker diagnostic method for DIC is needed. Under such circumstances, soluble C-type lectin-like receptor 2 (sCLEC-2) received attention as a biomarker for platelet activation. MATERIALS AND METHODS: The diagnostic usefulness of sCLEC-2 and several formulas, including sCLEC-2xD-dimer, sCLEC-2/platelet count (sCLEC-2/PLT), and sCLEC-2/PLT × D-dimer (sCLEC-2xD-dimer/PLT), were evaluated among 38 patients with DIC, 39 patients with pre-DIC and 222 patients without DIC or pre-DIC (non-DIC). RESULTS: Although the plasma level of sCLEC-2 alone was not a strong biomarker for the diagnosis of DIC or pre-DIC, the sCLEC-2xD-dimer/PLT values in patients with DIC were significantly higher than those in patients without DIC, and in a receiver operating characteristic (ROC) analysis for the diagnosis of DIC, sCLEC-2xD-dimer/PLT showed the highest AUC, sensitivity, and odds ratio. This formula is useful for the diagnosis of both pre-DIC and DIC. sCLEC-2xD-dimer/PLT values were significantly higher in non-survivors than in survivors. CONCLUSION: The sCLEC-2xD-dimer/PLT formula is simple, easy, and highly useful for the diagnosis of DIC and pre-DIC without the use of a scoring system.

Plasma Soluble Fibrin Is Useful for the Diagnosis of Thrombotic Diseases.

BACKGROUND: Soluble fibrin (SF) is a form of fibrinogen that is activated by thrombin and is considered to be useful for the diagnosis of the prethrombotic state or thrombosis. METHODS: Plasma levels of fibrin-related markers (FRMs), such as SF, D-dimer, fibrinogen, and fibrin degradation prioduct (FDP) levels in critically ill patients, were examined for the diagnosis of disseminated intravascular coagulation (DIC), venous thromboembolism (VTE), peripheral arterial thromboembolism (PATE), acute myocardial infarction (AMI), and acute cerebral infarction (ACI). RESULTS: FRMs showed the usefulness in diagnosing DIC and VTE and the cutoff values of D-dimer, FDP, and SF for DIC were 7.2-7.8 µg/mL, 10.0 µg/mL, and 9.5 µg/mL, respectively. The cutoff values of D-dimer and FDP for VTE were similar to the 97.5th percentile values of healthy volunteers, while the cutoff value of SF was 6.9 µg/mL. In AMI and ACI, the cutoff values of D-dimer and FDP were lower than the 97.5 percentile values of healthy volunteers. A receiver operating characteristic analysis for all thrombosis cases showed that an adequate cutoff value in only SF among FRMs was higher than the confidence interval of healthy volunteers. Only SF had high sensitivity for thrombosis, as the FDP/SF ratio was markedly low for ACI, AMI and VTE. CONCLUSIONS: FRMs, especially D-dimer and FDP, were useful for diagnosing thrombosis with hyperfibrinolysis (e.g., DIC). As SF showed high sensitivity for predominantly thrombotic diseases, including arterial thrombosis, such as ACI and AMI, a high SF value suggests the possibility of an association with thrombosis. Finally, SF is the most useful marker for raising suspicion of an association with thrombosis, especially arterial thrombosis.

Predictive prognostic biomarkers in patients with COVID­19 infection.

The present study aimed to identify useful biomarkers to predict deterioration in patients with coronavirus disease 2019 (COVID­19). A total of 201 COVID­19 patients were classified according to their disease severity into non­severe (n=125) and severe (n=76) groups, and the behavior of laboratory biomarkers was examined according to the prognosis. Neutrophil count, aspartate aminotransferase (AST), alanine aminotransferase, lactate dehydrogenase (LDH), C­reactive protein (CRP), sialylated carbohydrate antigen KL­6 (KL­6), procalcitonin (PCT), presepsin (PSP) and D­dimer levels were significantly higher, and lymphocyte count and platelet count were significantly lower in the non­severe group compared with the severe group. In the non­severe group, ROC analysis demonstrated that only four biomarkers, CRP, PSP, AST and LDH were useful for differentiating the prognosis between improvement and deterioration subgroups. No strong correlation was revealed for any of the markers. Multivariate analysis identified CRP as a significant prognostic factor in non­severe cases (odds ratio, 41.45; 95% confidence interval, 4.91­349.24; P<0.001). However, there were no blood biomarkers that could predict the outcome of patients in the severe group. Overall, several blood markers changed significantly according to disease severity in the course of COVID­19 infection. Among them, CRP, PSP, LDH and AST were the most reliable markers for predicting the patient's prognosis in non­severe COVID­19 cases.

Reply to Ishikura, H. What Does Soluble C-Type Lectin-like Receptor 2 (sCLEC-2) × D-Dimer/Platelet (PLT) (sCLEC-2 × D-Dimer/PLT) Mean for Coagulation/Fibrinolysis Conditions? Comment on "Yamamoto et al. Super Formula for Diagnosing Disseminated Intravascular Coagulation Using Soluble C-Type Lectin-like Receptor 2. Diagnostics 2023, 13, 2299".

We would like to thank Dr. Ishikura for his kind comment [...].

Elevated Plasma Soluble C-Type Lectin-like Receptor 2 Is Associated with the Worsening of Coronavirus Disease 2019.

Although thrombosis in coronavirus disease 2019 (COVID-19) infection has attracted attention, the mechanism underlying its development remains unclear. The relationship between platelet activation and the severity of COVID-19 infection was compared with that involving other infections. Plasma soluble C-type lectin-like receptor 2 (sCLEC-2) levels were measured in 46 patients with COVID-19 infection and in 127 patients with other infections. The plasma sCLEC-2 levels in patients with COVID-19 infection {median (25th, 75th percentile), 489 (355, 668) ng/L} were significantly higher (p < 0.001) in comparison to patients suffering from other pneumonia {276 (183, 459) ng/L}, and the plasma sCLEC-2 levels of COVID-19 patients with severe {641 (406, 781) ng/L} or critical illness {776 (627, 860) ng/L} were significantly higher (p < 0.01, respectively) in comparison to those with mild illness {375 (278, 484) ng/L}. The ratio of the sCLEC-2 levels to platelets in COVID-19 patients with critical illness of infection was significantly higher (p < 0.01, p < 0.001 and p < 0.05, respectively) in comparison to COVID-19 patients with mild, moderate or severe illness. Plasma sCLEC-2 levels were significantly higher in patients with COVID-19 infection than in those with other infections, suggesting that platelet activation is triggered and facilitated by COVID-19 infection.

Proposal of Quick Diagnostic Criteria for Disseminated Intravascular Coagulation.

BACKGROUND: The diagnostic criteria for disseminated intravascular coagulation (DIC) vary and are complicated and the cut-off values are different. Simple and quick diagnostic criteria for DIC are required in physicians for critical care. MATERIAL AND METHODS: Platelet counts, prothrombin time-international normalized ratio (PT-INR) and D-dimer levels were examined in 1293 critical ill patients. Adequate cut-off values of these parameters were determined and a quick DIC score using these biomarkers was proposed. The quick DIC score was evaluated using a receiver operating characteristic (ROC) analysis. RESULTS: Using the Japanese Ministry of Health, Labor and Welfare diagnostic criteria, 70 and 109 patients were diagnosed with DIC and pre-DIC, respectively. The ROC analysis of factors difference between DIC and non-DIC, revealed the following cut-off values: PT-INR, 1.20; platelet count, 12.0 × 1010/L and D-dimer, 10.0 µg/mL. Based on the above results, the quick DIC score system was proposed. All patients with DIC had a quick DIC score of 3, 4 or 5, and 85.3% of the patients with pre-DIC had a quick DIC score of ≥3 points. All patients with pre-DIC had a score of ≥2 points. In the ROC analysis, the area under the curve was 0.997 for DIC vs. non-DIC, and 0.984 for pre-DIC + DIC vs. non-DIC, and the cut-off value was 3 points for DIC and 2 points for DIC + pre-DIC. The quick DIC scores of non-survivors were significantly higher than those of survivors. CONCLUSIONS: The Quick DIC score system is a simple and useful tool that can be used for the diagnosis of DIC and pre-DIC. Further evaluation of the quick DIC score system in a large-scale study is required.

D-dimer kit with a High FDP/D-Dimer Ratio is Useful for Diagnosing Thrombotic Diseases.

INTRODUCTION: Although D-dimer is a useful biomarker of thrombosis, there are many D-dimer kits, with high and low fibrinogen and fibrin degradation products (FDP)/ D-dimer ratios. METHODS: Plasma D-dimer levels were measured using three different kits in critically ill patients to examine the usefulness of such measurements for detecting the thrombotic diseases and determining the correlation with the FDP and FDP/D-dimer ratio. RESULTS: Although three D-dimer kits showed marked utility for diagnosing disseminated intravascular coagulation (DIC) and peripheral arterial and venous thromboembolism (PAVTE), the D-dimer levels determined using the three kits varied among diseases. Indeed, one D-dimer kit showed a high FDP/D-dimer ratio, and another kit showed a low FDP/D-dimer ratio. D-dimer kit with low FDP/D-dimer ratio tended to have high cut-off values and low specificity for diagnosing DIC and PAVTE. In D-dimer kit with high FDP/D-dimer ratio, FDP/D-dimer ratios in patients with thrombosis was significantly higher than that in patients without thrombosis. CONCLUSION: All three D-dimer kits show utility for detecting thrombotic diseases. However, the D-dimer levels determined using the kits varied due to differences in the FDP/D-dimer ratio. In combination with the FDP level, a D-dimer kit with a high FDP/D-dimer ratio may be useful.

Evaluation of Biomarkers of Severity in Patients with COVID-19 Infection.

OBJECT: Although many Japanese patients infected with coronavirus disease 2019 (COVID-19) only experience mild symptoms, in some cases a patient's condition deteriorates, resulting in a poor outcome. This study examines the behavior of biomarkers in patients with mild to severe COVID-19. METHODS: The disease severity of 152 COVID-19 patients was classified into mild, moderate I, moderate II, and severe, and the behavior of laboratory biomarkers was examined across these four disease stages. RESULTS: The median age and male/female ratio increased with severity. The mortality rate was 12.5% in both moderate II and severe stages. Underlying diseases, which were not observed in 45% of mild stage patients, increased with severity. An ROC analysis showed that C-reactive protein (CRP), ferritin, procalcitonin (PCT), hemoglobin (Hb) A1c, albumin, and lactate dehydrogenase (LDH) levels were significantly useful for the differential diagnosis of mild/moderate I stage and moderate II/severe stage. In the severe stage, Hb levels, coagulation time, total protein, and albumin were significantly different on the day of worsening from those observed on the day of admission. The frequency of hemostatic biomarker abnormalities was high in the severe disease stage. CONCLUSION: The evaluation of severity is valuable, as the mortality rate was high in the moderate II and severe stages. The levels of CRP, ferritin, PCT, albumin, and LDH were useful markers of severity, and hemostatic abnormalities were frequently observed in patients in the severe disease stage.

Soluble C-Type Lectin-Like Receptor 2 Elevation in Patients with Acute Cerebral Infarction.

BACKGROUND: Acute cerebral infarction (ACI) includes cardiogenic ACI treated with anticoagulants and atherosclerotic ACI treated with antiplatelet agents. The differential diagnosis between cardiogenic and atherosclerotic ACI is still difficult. MATERIALS AND METHODS: The plasma sCLEC-2 and D-dimer levels were measured using the STACIA system. RESULTS: The plasma sCLEC-2 level was significantly high in patients with ACI, especially those in patients with atherosclerotic or lacunar ACI, and plasma D-dimer levels were significantly high in patients with cardioembolic ACI. The plasma levels of sCLEC-2 and the sCLEC-2/D-dimer ratios in patients with atherosclerotic or lacunar ACI were significantly higher than those in patients with cardioembolic ACI. The plasma D-dimer levels in patients with atherosclerotic or lacunar ACI were significantly lower than those in patients with cardioembolic ACI. The plasma levels of sCLEC-2 and the sCLEC-2/D-dimer ratios were significantly higher in patients with atherosclerotic or lacunar ACI or acute myocardial infarction in comparison to patients with cardioembolic ACI or those with deep vein thrombosis. CONCLUSION: Using both the plasma sCLEC-2 and D-dimer levels may be useful for the diagnosis of ACI, and differentiating between atherosclerotic and cardioembolic ACI.

Soluble C-Type Lectin-Like Receptor 2 Is a Biomarker for Disseminated Intravascular Coagulation.

Disseminated intravascular coagulation (DIC) is induced by excess activation coagulation, and activated platelets are also involved in pathogenesis. Therefore, plasma levels of soluble C-type lectin-like receptor 2 (sCLEC-2), a new marker for platelet activation, can be expected as a marker of DIC in critically ill patients. Plasma levels of sCLEC-2 and D-dimer were measured using the STACIA system. Plasma sCLEC-2 and D-dimer levels were significantly higher in patients with underlying diseases of DIC than in those with unidentified clinical syndrome (UCS). Plasma sCLEC-2 levels were significantly higher in the patients with DIC and Pre-DIC than in those without DIC or Pre-DIC. Similarly, plasma D-dimer levels were also significantly higher in patients with DIC and Pre-DIC than in those without DIC or Pre-DIC. The plasma sCLEC-2 levels in all patients and those with a DIC score ≤ 4 were significantly higher in non-survivors than survivors. The plasma D-dimer levels in all patients, those with a DIC score ≥ 5 and those with a DIC score ≤ 4, were significantly higher in non-survivors than in survivors. The plasma sCLEC-2 is expected as a marker for DIC/Pre-DIC as well as the prognostic marker in critically ill patients.

Low-reflective wire-grid polariser sheet in the visible region fabricated by a nanoprinting process.

For the construction of next-generation optical products and systems, the evolution of polariser sheets is a necessary requirement. To this end, a low-reflective wire-grid polariser (WGP) sheet for the visible light region is demonstrated, the nanowires of which consist of a sintered body of silver nanoparticle ink. The nanowires are formed by a nanoprinting process using a thermal nanoimprint method and ink filling. This process makes it easier to achieve multiple wafer-scale productions without using sophisticated equipment compared to conventional WGP nanofabrication techniques, which typically employ lithography and elaborate etching processes. The optical characteristics are controlled by the shape of the printed nanowires. A WGP sheet with a luminous degree of polarisation of 99.0%, a total luminous transmittance of 13.6%, and a luminous reflectance of 3.6% is produced. Its low reflectance is achieved through the uneven surface derived from the sintered body of the nanoparticle ink, and the shape of the bottom of the nanowire is derived from the tip shape of the mould structure. Furthermore, the printed WGP sheet has the durability required for the manufacturing of curved products, including sunglasses. The optical structures made of nanoparticle ink using this nanoprinting process have the potential to significantly contribute to the development of fine-structured optical elements with unprecedented functionality.

Elevated D-Dimer Levels Predict a Poor Outcome in Critically Ill Patients.

D-dimer is a biomarker of thrombosis and recently been considered to predict a poor outcome in patients with infectious diseases. Plasma D-dimer levels were measured in critically ill patients to examine their relationship with the poor outcome. The plasma D-dimer levels were markedly higher in the patients with various underlying disease especially venous thromboembolism in comparison to those without severe underlying diseases. The plasma D-dimer levels in non-survivors were significantly higher than those in survivors. In a receiver operating characteristic analysis, the area under the curve was high for the disseminated intravascular coagulation (DIC) score, the D-dimer value, and the prothrombin time-international normalize ratio (PT-INR). Adequate cut-off values for predicting the outcome were 3 as follows: DIC score, 3 points; D-dimer, 4.2 mg/L; and PT-INR, 1.08. D-dimer, which is a biomarker for thrombosis, is increased in various underlying diseases and predicts a poor outcome.

Penetrating nail-gun injury of the thoracic descending aorta.

Penetrating injury of the descending aorta due to accidental discharge of a nail gun.

Cortical blindness induced by hepatic encephalopathy: case report and review of published case reports.

Case: Cortical blindness induced by hepatic encephalopathy is an extremely rare complication and its epidemiology has not been studied in great detail. We report a 63-year-old man with liver cirrhosis who developed sudden bilateral visual impairment. Outcome: On arrival at hospital, the patient had orientation disturbance, slurred speech, and mild disturbance of consciousness with impaired vision (light sense). He had no focal neurological deficits except for bilateral blindness. Cerebral stroke was suspected, but imaging and ophthalmological examination did not reveal major abnormalities. An increased concentration of ammonia in blood suggested hepatic encephalopathy; a diagnosis of cortical blindness was proposed. His vision returned gradually with relief of hepatic encephalopathy. Conclusion: Cortical blindness can be an initial symptom of hepatic encephalopathy without severe disturbance of consciousness, and can be misdiagnosed as cerebral stroke. Cortical blindness induced by hepatic encephalopathy has been reported in only 10 cases, including our patient, and merits further evaluation.

Basi-parallel anatomical scanning-magnetic resonance imaging for the diagnosis of reversible cerebral vasoconstriction syndrome of the basilar artery: a case report.

Case: Reversible cerebral vasoconstriction syndrome (RCVS) is an increasingly recognized and important cause of thunderclap headache. Delays in diagnosis may cause deterioration of symptoms and concomitant unnecessary investigations. However, the diagnosis of RCVS in the acute stage remains difficult.A 41-year-old man was admitted to the emergency department for severe, recurrent occipital headaches. The results of initial computed tomography and magnetic resonance imaging (MRI) of the brain and cerebrospinal fluid analysis were normal. Magnetic resonance angiography (MRA) showed multisegmental luminal stenosis of the basilar artery. Basi-parallel anatomical scanning (BPAS)-MRI, illustrating the outer contour of the vertebrobasilar artery, also showed multisegmental stenosis. Outcome: The patient was speculated as having RCVS and was treated with oral lomerizine hydrochloride. Repeat MRA and BPAS-MRI 2 months later showed resolution, confirming RCVS. Conclusion: Combined with MRA, BPAS-MRI is an effective and non-invasive imaging method for diagnosis of RCVS of the basilar artery.

Postmortem diagnosis of massive gastrointestinal bleeding in a patient with aberrant right subclavian artery-esophageal fistula.

Case: Aberrant right subclavian artery-esophageal fistula is a rare, but fatal, complication. A 55-year-old febrile man with a nasogastric feeding tube developed sudden massive hematemesis and shock. Outcome: Upper endoscopy revealed an intragastric hematoma with no active bleeding observed except for oozing from an esophageal tear. Enhanced computed tomography scan detected aberrant right subclavian artery but was unable to determine the bleeding source. Repeat endoscopy carried out on day 2 confirmed hemostasis and the disappearance of the intragastric hematoma. However, the patient suddenly developed recurrent massive hematemesis with refractory shock on day 4 and died. Postmortem computed tomography revealed endoscopic clips in contiguity with aberrant right subclavian artery; a final diagnosis of aberrant right subclavian artery-esophageal fistula was made. Conclusion: Our case demonstrates aberrant right subclavian artery-esophageal fistula may present with transient spontaneous hematemesis in a state of shock, possibly related to fever of unknown origin, and is challenging to diagnose by repeated endoscopy once hematemesis develops.

Management of inadvertent vertebral artery injury due to central venous catheterization in a coagulopathic patient.

Case: A 72-year-old man was admitted to the intensive care unit for severe pancreatitis with coagulopathy. He underwent hemodialysis catheter insertion into the internal jugular vein that subsequently leaked arterial blood; vertebral artery cannulation was suspected following a computed tomography scan. Outcome: Under angiographic guidance, the catheter was removed, and an arteriovenous fistula was identified. The patient was successfully treated with endovascular embolization of the affected vertebral artery with detachable coils and N-butyl-2-cyanoacrylate. Conclusion: Despite ultrasound guidance, vertebral cannulation can occur, which can result in serious complications. Prompt management is needed to prevent further sequelae. Endovascular embolization with detachable coils and N-butyl-2-cyanoacrylate appears to be an effective option for vertebral artery injury in patients with coagulopathy.

Controlled normothermia for a cerebral air embolism complicating computed tomography-guided transthoracic needle biopsy of the lung.

Case: A 74-year-old woman underwent computed tomography-guided transthoracic needle biopsy of a small lung mass. Immediately after the procedure, she lost consciousness. After resuscitation, her brain computed tomography scan confirmed a cerebral air embolism. Outcome: As hyperbaric oxygenation was unavailable, she received controlled normothermia for neuroprotection. No cerebral symptoms were observed following treatment. Conclusion: Air embolisms are rare, but fatal, complications of computed tomography-guided transthoracic needle biopsy. Therefore, clinicians should be familiar with early diagnosis and prompt treatment. Preventing hyperthermia might be effective for treating hypoxic brain injury caused by cerebral air embolisms.