Correction: Comparison of professionalism between emergency medicine resident physicians and faculty physicians: A multicenter cross-sectional study.

[This corrects the article DOI: 10.1371/journal.pone.0230186.].

Factors for delays in door-to-balloon time ≤ 90 min in an electrocardiogram triage system among patients with ST-segment elevation myocardial infarction: a retrospective study.

BACKGROUND: Door to balloon time is a crucial factor of mortality in patients with ST-segment elevation myocardial infarction. However, the factors that contribute to failure of achieving door to balloon time ≤ 90 min in an electrocardiogram triage system remain unknown. METHODS: This single-center retrospective observational study collected data from consecutive patients with ST-segment elevation myocardial infarction from April 2016 to March 2021. The primary outcome was the failure to achieve door to balloon time ≤ 90 min. A multivariate logistic regression model was performed to predict factors associated with failure to achieve door to balloon time ≤ 90 min. RESULTS: In total, 190 eligible patients were included. Of these, the 139 (73.2%) patients with door to balloon time ≤ 90 min were significantly younger compared to those with door to balloon time > 90 min (p = 0.02). However, there was no significant difference in sex and timing of hospital arrival between the door to balloon time ≤ 90 and > 90 min groups. Presence of chest pain and ambulance usage were significantly more frequent in patients with door to balloon time ≤ 90 min (p ≤ 0.01, p = 0.02, respectively). Multivariate analysis showed that absence of chest pain (adjusted odds ratio 4.76; 95% confidence interval, 2.04-11.1; p < 0.01) and non-ambulance usage (adjusted odds ratio 3.53; 95% confidence interval, 1.57-7.94; p < 0.01) are predictive factors of failure to achieve door to balloon time ≤ 90 min. CONCLUSION: Patients without chest pain as the chief complaint or non-ambulance usage were significantly associated with the failure to achieve door to balloon time ≤ 90 min.

Association between capnography and recovery time after procedural sedation and analgesia in the emergency department.

Aim: Capnography is recommended for use in procedural sedation and analgesia (PSA); however, limited studies assess its impact on recovery time. We investigated the association between capnography and the recovery time of PSA in the emergency department (ED). Methods: This study was a secondary analysis of a multicenter PSA patient registry including eight hospitals in Japan. We included all patients who received PSA in the ED between May 2017 and May 2021 and divided the patients into capnography and no-capnography groups. The primary outcome was recovery time, defined as the time from the end of the procedure to the cessation of monitoring. The log-rank test and multivariable analysis using clustering for institutions were performed. Results: Of the 1265 screened patients, 943 patients who received PSA were enrolled and categorized into the capnography (n = 150, 16%) and no-capnography (n = 793, 84%) groups. The median recovery time was 40 (interquartile range [IQR]: 25-63) min in the capnography group and 30 (IQR: 14-55) min in the no-capnography group. In the log-rank test, the recovery time was significantly longer in the capnography group (p = 0.03) than in the no-capnography group. In the multivariable analysis, recovery time did not differ between the two groups (adjusted hazard ratio, 0.95; 95% confidence interval, 0.77-1.17; p = 0.61). Conclusion: In this secondary analysis of the multicenter registry of PSA in Japan, capnography use did not associate with shorter recovery time in the ED.

Burnout among Japanese emergency medicine physicians: A multicentric questionnaire study.

Objective: Burnout negatively affects the wellness and performance of emergency physicians (EPs). This study aimed to clarify the actual prevalence of burnout and its associated factors among Japanese EPs. Methods: We conducted a cross-sectional questionnaire study of selected 27 Japanese emergency departments (EDs). We examined the Maslach Burnout Inventory-Human Services Survey score and its associations with ED-level- and EP-level factors in a multivariable analysis. Results: A total of 267 EPs (81.9%) completed survey. Of these, 43 EPs (16.1%) scored severe emotional exhaustion (EE), 53 (19.8%) scored severe depersonalization (DP), and 179 (67.0%) scored severe personal accomplishment (PA), and 24 (8.9%) scored severely in all three domains. In our multivariable analysis, emergency medical service centers were associated with severe PA scores (odds ratio [OR], 10.56; 95% confidence interval [CI], 1.78-62.66; p = 0.009). A 3 to 6 hour-sleep period was associated with severe EE scores (OR, 2.04; 95% CI, 1.04-3.98; p = 0.036), and EPs in their 20s were associated with severe DP scores (OR, 7.37; 95% CI, 1.41-38.38; p = 0.018). Conclusion: Our results suggest that 8.9% of Japanese EPs are in higher degrees of burnout. In particular, Japanese EPs scored more severely on PA. To avoid burnout in Japanese EPs, it is important to improve the working environment by ensuring more than 6 h of sleep, providing more support for young EPs, and taking effective action to combat low EP self-esteem.

Higher nursing care level is associated with higher incidence of blood culture contamination in the emergency department: A case-control study.

Background: Blood culture is critical in treating infectious diseases. This leads to unnecessary intervention, inappropriate antibiotic use, and excess cost. Few studies have tackled patient factors that could possibly affect contamination rates. This study aimed to explore the association between patients' nursing care levels and blood culture contamination. Methods: This is a single-centered, retrospective, case-control study of adult patients whose blood culture specimens were taken in the emergency department between April 2018 and July 2019. The study was conducted in an acute care community hospital in Japan. The case group included patients with false-positive blood culture results with contamination; the control group included patients with true-positive or true-negative blood culture results without contamination. We randomly selected two control patients per case. Patients' age, gender, nursing care level, ambulance use, housing status, Glasgow Coma Scale, hospital arrival time, and puncture sites were obtained from the patients' medical charts. Results: Of the 5130 patients, 686 patients got positive blood culture results. Of the 686 patients, 35 patients were included in the case group, and 70 were randomly selected from the noncontaminated group and included in the control. In multivariate analysis, patients with contaminated blood cultures had a higher nursing care level (adjusted odds ratio: 8.50; 95% confidence interval: 1.65-43.7; p = 0.01). Conclusions: A higher nursing care level is associated with a higher incidence of blood culture contamination in the emergency department. Careful and appropriate procedures are required for patients with a higher nursing care level.

Effectiveness of point of care ultrasound (POCUS) simulation course and skills retention for Japanese nurse practitioners.

BACKGROUND: In Japan, the nurse practitioner (NP) system has only been in place for a short time, and there is no ultrasound (US) simulation course for NPs. Therefore, NPs may have to attend US simulation courses for physicians. We evaluated whether US simulation course for physicians lead to improved image acquisition and interpretation amongst NPs and, if so, if these changes would be maintained over time. METHODS: A 2-day point-of-care ultrasound (POCUS) course designed for physicians in cardiac US, lung US, lower extremity deep vein thrombosis (DVT) US, and abdominal US was held for Japanese nurse practitioners (JNP) and JNP trainees in 2018 and 2019. Participants kept a record of the number of US examinations they performed for 3 months before and 3 months after the course. The number of US exams performed was grouped into six categories. All participants underwent pre-course, immediate post-course, and 4-month post-course testing to assess image interpretation skills, image acquisition skills, and confidence. RESULTS: Thirty-three participants from 21 facilities completed the program. Before and immediately after the course, test scores of the image interpretation test, image acquisition test, and confidence increased significantly (37.1, 72.6: P < 0.001), (13.7, 53.6: P < 0.001), and (15.8, 35.7: P < 0.001), respectively. Comparing the follow-up tests immediately after the course and 4 months later, there was no decrease in scores on the image interpretation test, the image acquisition test, or confidence (72.6, 71.8: P = 1.00) (53.6, 52.9: p = 1.00) (35.7, 33.0: P = 0.34). There was a statistically significant increase (P < 0.001) in both the total number of ultrasound examinations and in the number of ultrasound examinations by category (cardiac, lung, lower extremity DVT, and abdominal) in the 3 months before and 3 months after the course. CONCLUSIONS: The POCUS simulation course for physicians is useful for JNPs to acquire US examination skills even if it is not arranged for JNPs. Image interpretation skill, image acquisition skill, and confidence improved significantly and were maintained even after 4 months of the course. It leads to behavioral changes such as increasing the number of US examinations in daily practice after the course.

Association of antiplatelet or anticoagulant agents with in-hospital mortality among blunt torso trauma patients without severe traumatic brain injury: A retrospective analysis of the Japanese nationwide trauma registry.

AIM: Patients with head trauma who take antiplatelet or anticoagulant (APAC) agents have a higher rate of mortality. However, the association between these agents and mortality among blunt torso trauma patients without severe traumatic brain injury remains unclear. METHODS: Using the Japanese nationwide trauma registry, we conducted a retrospective cohort study including adult patients with blunt torso trauma without severe head trauma between January 2019 and December 2020. Eligible patients were divided into two groups based on whether or not they took any APAC agents. The primary outcome was in-hospital mortality. To adjust for potential confounding factors, we conducted random effects logistic regression to account for patients clustering within the hospitals. The model was adjusted for potential confounders, including age, mechanism of injury, Charlson comorbidity index, systolic blood pressure, and injury severity scale on arrival as potentially confounding factors. RESULTS: During the study period, 16,201 patients were eligible for the analysis. A total of 832 patients (5.1%) were taking antiplatelet or anticoagulant agents. Overall in-hospital mortality was 774 patients (4.8%). APAC group had a higher risk of in-hospital mortality compared with the non-APAC group (6.9% vs. 4.7%; unadjusted OR, 1.51; 95% CI, 1.12-2.00; P < 0.01). After adjusting for potential confounder, there were no significant intergroup difference in a higher in-hospital mortality compared to with the non-APAC group (OR, 1.07; 95%CI, 0.65-1.77; P = 0.79). CONCLUSION: The use of APAC agents before the injury was not associated with higher in-hospital mortality among blunt torso trauma patients without severe traumatic brain injury.

Recurrent abdominal pain in an older woman: Enlarged OE-P gap on computed tomography as an indicator of non-strangulated obturator hernia.

Obturator hernia (OH) is a relatively rare abdominal wall hernia with a high mortality rate. The diagnosis of OH is challenging because of symptomatic variations and spontaneous reduction in hernia on imaging. An 89-year-old woman presented to our emergency department with pain in the abdomen and right groin. Computed tomography (CT) revealed an incarcerated small bowel in the gap between the obturator externus and pectineus (OE-P gap). Symptoms disappeared after manual reduction. She experienced these same symptoms intermittently during the past year and underwent abdominal CT 4 times after disappearance of symptoms. The CT scans at each previous visit showed an enlarged OE-P gap (an average of 80 mm) compared with the asymptomatic side (an average of 34 mm). An enlarged OE-P gap on CT images taken after disappearance of symptoms could be a sign of spontaneously reduced OH.

Changes in the Treatment for Out-of-Hospital Cardiac Arrest During the Initial Stage of the COVID-19 Outbreak in Japan.

INTRODUCTION: Cardiopulmonary resuscitation (CPR) for out-of-hospital cardiac arrest (OHCA) patients during the coronavirus disease 2019 (COVID-19) pandemic carries an added risk of COVID-19 infection for healthcare workers. However, because of the shortage of medical supplies and limited evidence of COVID-19 in the initial stages of the pandemic, strategies for the management of OHCA patients may have varied across hospitals. METHOD: A web-based questionnaire was used. The first section collected data about physician characteristics. In the second section, participants responded "Yes" or "No," if they had made changes in the areas of "personal protective equipment (PPE)" or "CPR Algorithm" for OHCA patients (these changes were the personal views of the surveyed respondents). The questionnaire was sent to the members of the Emergency Medicine Alliance mailing list. The response period was from May 22 to June 5, 2020 (the first state of emergency related to COVID-19 was declared on April 7, 2020, in Japan). Participants were asked to indicate their stress level resulting from these changes using the Likert scale ranging from 1 to 10, where 1 = "no stress" and 10 = "severe stress." RESULT: A total of 110 physicians responded during the study period. The majority of participants reported changes in "PPE" (n = 106, 96.4%) and "CPR Algorithm" (n = 86, 78.2%). The reported stress level due to changes in PPE was 8 (IQR 6-9) and due to changes in the CPR algorithm, it was 7 (IQR 5-8). CONCLUSION: Findings of this study suggest that physicians experienced changes in care for OHCA patients and felt stress during the initial stage of the COVID-19 pandemic. Thus, it would be better to list the actual measures that can be undertaken to prepare for any future pandemics.

Left atrial appendage rupture: A rare complication of right-sided haemothorax: A case report.

Cardiac injury accounts for less than 10 % of all traumas and it is a fatal condition associated with cardiac tamponade or massive haemothorax, which requires immediate intervention, such as resuscitative thoracotomy. However, in case of haemothorax without the findings suggestive of cardiac damage such as pericardial effusion, it is difficult to determine the complications of cardiac injury, because injury of the lung or intercostal arteries is usually considered first. We describe a rare case of left atrial appendage rupture with a right-sided massive haemothorax with slight cardiac effusion. A 47-year-old man with no significant medical history was transferred to our emergency department after crashing his motorcycle into a car. A right resuscitative thoracotomy for massive haemothorax was performed, followed by hilarious clamping and pericardial drainage. We found continuous bleeding from a right dorsal pericardial injury which indicated cardiac injury. Soon after the patient was referred to the operating room, left atrial appendage rupture was found, and ligated. The postoperative course was uneventful, and he was discharged on 15th postoperative day without complication. Left atrial appendage rupture is caused by a direct external force to the left atrium, so the pericardial injury is usually ipsilateral to the left side of the pericardium, resulting in perforation of the left thoracic cavity. Therefore, left atrial appendage rupture with a right-sided massive haemothorax is rare. In addition, when a cardiac injury is associated with a pericardial injury, most of the pericardial effusion drains into the thoracic cavity, resulting in a small amount of pericardial effusion, which make it difficult to recognize the cardiac injury. In conclusion, in blunt trauma, even in the case of a right-sided haemothorax, the possibility of cardiac injury in addition to pulmonary contusion should be considered and explored, because cardiac injury could be fatal.

Transcatheter arterial embolization for postoperative hemorrhage complicating surgical repair of incarcerated umbilical hernia subsequent to Denver peritoneovenous shunting: A case report.

A 50-year-old man with a refractory ascites was inserted a peritoneovenous shunt under local anesthesia. On the fifth postoperative day, abdominal pain occurred and were diagnosed as incarcerated umbilical hernia. Due to unsuccessful manual reduction, emergent hernia repair was performed. Postoperatively, wound bleeding was not controlled, and endovascular treatment was planned because enhanced computed tomography detected arterial extravasations. Bilateral inferior epigastric arteries were embolized with a 33.3% n-butyl-2-cyanoacrylate lipiodol mixture. The patient's symptoms subsequently improved without complications. Patients with refractory ascites develop incarcerated umbilical hernia after the decompression procedure, such as a peritoneovenous shunt. The coagulopathy caused by the Denver peritoneovenous shunt makes perioperative bleeding control difficult. Therefore, physicians should be aware that laparotomy performed after Denver peritoneovenous shunting sometimes requires transarterial embolization for hemostasis.

Integrated model for COVID-19 diagnosis based on computed tomography artificial intelligence, and clinical features: a multicenter cohort study.

Background: We developed and validated a machine learning diagnostic model for the novel coronavirus (COVID-19) disease, integrating artificial-intelligence-based computed tomography (CT) imaging and clinical features. Methods: We conducted a retrospective cohort study in 11 Japanese tertiary care facilities that treated COVID-19 patients. Participants were tested using both real-time reverse transcription polymerase chain reaction (RT-PCR) and chest CTs between January 1 and May 30, 2020. We chronologically split the dataset in each hospital into training and test sets, containing patients in a 7:3 ratio. A Light Gradient Boosting Machine model was used for the analysis. Results: A total of 703 patients were included, and two models-the full model and the A-blood model-were developed for their diagnosis. The A-blood model included eight variables (the Ali-M3 confidence, along with seven clinical features of blood counts and biochemistry markers). The areas under the receiver-operator curve of both models [0.91, 95% confidence interval (CI): 0.86 to 0.95 for the full model and 0.90, 95% CI: 0.86 to 0.94 for the A-blood model] were better than that of the Ali-M3 confidence (0.78, 95% CI: 0.71 to 0.83) in the test set. Conclusions: The A-blood model, a COVID-19 diagnostic model developed in this study, combines machine-learning and CT evaluation with blood test data and performs better than the Ali-M3 framework existing for this purpose. This would significantly aid physicians in making a quicker diagnosis of COVID-19.

Disseminated tuberculosis following invasive procedures for peripancreatic lymph node tuberculosis with portal vein obstruction: a case report.

Peripancreatic tuberculous lymphadenopathy can mimic pancreatic cancer on imaging. There have only a few reports on varices from portal vein obstruction due to abdominal tuberculous lymphadenopathy. Iatrogenic disseminated tuberculosis is also rare. Herein, we present a rare case of peripancreatic tuberculous lymphadenopathy with ruptured duodenal varices due to portal vein obstruction. The patient presented to our hospital with hematemesis. Computed tomography revealed a peripancreatic mass. Duodenal varices rupture from portal vein obstruction due to pancreatic cancer were initially suspected. The patient underwent portal vein stenting for portal vein obstruction and endoscopic ultrasound-guided fine-needle aspiration for diagnosis, which revealed granulomas indicative of tuberculosis. The patient was discharged once because fine-needle aspiration did not lead to a definitive diagnosis of tuberculosis. Subsequently, he developed disseminated tuberculosis. Peripancreatic tuberculous lymphadenopathy can cause ectopic varices with portal vein obstruction. Tuberculosis should also be included in the differential diagnosis in the case of portal vein obstruction, to facilitate early treatment and avoid unnecessary surgery. Furthermore, fine-needle aspiration or portal vein stenting for tuberculous lesions can cause disseminated tuberculosis. Since a diagnosis might not be made until after several fine-needle aspirations have been conducted, careful follow-up is necessary after the procedure for such lesions.

Association Between Repeated Tracheal Intubation Attempts and Adverse Events in Children in the Emergency Department.

STUDY OBJECTIVES: Studies have shown that multiple intubation attempts are associated with a higher risk of intubation-related adverse events. However, little is known about the relationship in children in the emergency department (ED). METHODS: This is an analysis of the data from 2 prospective, observational, multicenter registries of emergency airway management. The data were collected from consecutive patients who underwent emergency airway management in 19 EDs across Japan from March 2010 to November 2017. We included children 18 years or younger who underwent tracheal intubation in the ED. The primary exposure was the number of intubation attempts (1 vs ≥2). The primary outcome was an adverse event during or immediately after the intubation. RESULTS: A total of 439 children were eligible for the analysis. Of 279 children with first-pass success, 24 children (9%) had an adverse event. By contrast, of 160 children with ≥2 intubation attempts, 50 children patients (31%) had an adverse event. In the unadjusted model, multiple intubation attempts were significantly associated with a higher rate of adverse events (unadjusted odds ratio, 4.83; 95% confidence interval, 2.57-9.06; P < 0.001). This association remained significant after adjusting for 7 potential confounders and patient clustering within the hospital (adjusted odds ratio, 4.49; 95% confidence interval, 2.36-8.53; P < 0.001). Similar associations were found across different age groups and among children without cardiac arrest (all, P < 0.05). CONCLUSIONS: In this analysis of large prospective multicenter data, multiple intubation attempts were associated with a significantly higher rate of intubation-related adverse events in children in the ED.