Current status of active cooling, deep body temperature measurement, and face mask wearing in heat stroke and heat exhaustion patients in Japan: a nationwide observational study based on the Heatstroke STUDY 2020 and 2021.

Aim: The study aimed to determine the current status of face mask use, deep body temperature measurement, and active cooling in patients suffering from heat stroke and heat exhaustion in Japan. Methods: This was a prospective, observational, multicenter study using data from the Heatstroke STUDY 2020-2021, a nationwide periodical registry of heat stroke and heat exhaustion patients. Based on the Bouchama heatstroke criteria, we classified the patients into two groups: severe and mild-to-moderate. We compared the outcomes between the two groups and reclassified them into two subgroups according to the severity of the illness, deep body temperature measurements, and face mask use. Cramer's V was used to determine the effect sizes for a comparison between groups. Results: Almost all patients in this study were categorized as having degree III based on the Japanese Association for Acute Medicine heatstroke criteria (JAAM-HS). However, the severe group was significantly worse than the mild-to-moderate group in outcomes like in-hospital death and modified Rankin Scale scores, when discharged. Heat strokes had significantly higher rates of active cooling and lower mortality rates than heat stroke-like illnesses. Patients using face masks often use them during labor, sports, and other exertions, had less severe conditions, and were less likely to be young male individuals. Conclusions: It is suggested that severe cases require a more detailed classification of degree III in the JAAM-HS criteria, and not measuring deep body temperature could have been a factor in the nonperformance of active cooling and worse outcomes.

Novel score for predicting early emergency endovascular therapy in trauma care using logistic LASSO regression.

Aim: To support decision-making for early interventional radiology, this study aimed to derive and validate a novel and simple scoring system for predicting the necessity of interventional radiology therapies in trauma patients. Methods: This retrospective study used data derived from the medical records of patients with severe traumatic injuries treated at a tertiary-level emergency institution. The score was derived from 168 patients treated between April 2015 and October 2016 and validated using data from 68 patients treated between November 2016 and July 2017. Logistic "least absolute shrinkage and selection operator (LASSO)" regression was used to select predictors. In order to compose the score, odds ratios derived from the logistic model were simplified to integer score coefficients. The score was evaluated using the area under the receiver operating characteristic curve. The best cut-off point for the score was determined using Youden's index, and sensitivity and specificity were calculated. Results: The derived score comprised three predictors (systolic blood pressure, positive findings in abdominal ultrasound assessment, and pelvic fracture) and ranged from 0 to 30. On validation, the area under the receiver operating characteristic curve for the score was 0.86 (95% confidence interval, 0.64-1.00). The sensitivity and specificity were 80% and 89%, respectively, with a cut-off point of 3. Conclusion: This simple score, requiring variables obtainable immediately after hospital arrival, could aid in facilitating early interventional radiology team activation.

Serum D-dimer level as a predictor of neurological functional prognosis in cases of head injuries caused by road traffic accidents.

BACKGROUND: The number of traffic fatalities is declining in Japan; however, a large proportion of head injuries are still attributable to traffic accidents. Severe head trauma may cause progressive and devastating coagulopathy owing to exacerbated coagulation and fibrinolysis, which results in massive bleeding and poor patient outcomes. D-dimer is a fibrinolytic marker, which remarkably increases in severe coagulopathy due to the exacerbated fibrinolytic system. Because the degree of coagulopathy is associated with patient outcomes, the D-dimer level is a useful prognostic predictor in patients with head trauma. However, the usefulness of D-dimer in cases of head trauma caused by road traffic accidents remains inadequately explored. In this study, we investigated the relationship between D-dimer levels and outcomes in head injuries caused by traffic accidents. METHODS: We extracted data on traffic injuries from Japan Neuro-Trauma Data Bank Project 2015, which is a prospective multicenter registry of head injuries. The analysis included 335 individuals with no missing data. The outcome variable was the score of the Glasgow Outcome Scale (GOS), a neurological outcome index. The participants were categorized into the favorable outcome (GOS score ≥ 4) and poor outcome (GOS score ≤ 3) groups. The serum D-dimer levels at the time of admission were divided into four categories at the quartiles, and the reference category was less than the first quartile (< 17.4 µg/mL). We performed a logistic regression analysis with GOS as the dependent variable and D-dimer as a predictor and performed a multivariate analysis that was adjusted for 10 physiological parameters. RESULTS: In the univariate analysis, all groups with serum D-dimer values ≥ 17.4 µg/dL showed significantly poorer outcomes than those of the reference group. In the multivariate analysis, after adjusting for other factors, D-dimer levels ≥ 89.3 µg/dL were an independent predictor of poor outcome. CONCLUSION: After adjusting for physiological parameters, high serum D-dimer levels can be an independent factor for predicting neurological prognosis in head trauma caused by road traffic accidents.

Influence of the coronavirus disease 2019 (COVID-19) pandemic on the incidence of heat stroke and heat exhaustion in Japan: a nationwide observational study based on the Heatstroke STUDY 2019 (without COVID-19) and 2020 (with COVID-19).

AIM: To assess heat stroke and heat exhaustion occurrence and response during the coronavirus disease 2019 pandemic in Japan. METHODS: This retrospective, multicenter, registry-based study describes and compares the characteristics of patients between the months of July and September in 2019 and 2020. Factors affecting heat stroke and heat exhaustion were statistically analyzed. Cramér's V was calculated to determine the effect size for group comparisons. We also investigated the prevalence of mask wearing and details of different cooling methods. RESULTS: No significant differences were observed between 2019 and 2020. In both years, in-hospital mortality rates just exceeded 8%. Individuals >65 years old comprised 50% of cases and non-exertional onset (office work and everyday life) comprised 60%-70%, respectively. The recommendations from the Working Group on Heat Stroke Medicine given during the coronavirus disease pandemic in 2019 had a significant impact on the choice of cooling methods. The percentage of cases, for which intravascular temperature management was performed and cooling blankets were used increased, whereas the percentage of cases in which evaporative plus convective cooling was performed decreased. A total of 49 cases of heat stroke in mask wearing were reported. CONCLUSION: Epidemiological assessments of heat stroke and heat exhaustion did not reveal significant changes between 2019 and 2020. The findings suggest that awareness campaigns regarding heat stroke prevention among the elderly in daily life should be continued in the coronavirus disease 2019 pandemic. In the future, it is also necessary to validate the recommendations of the Working Group on Heatstroke Medicine.

Phenytoin versus other antiepileptic drugs as treatments for status epilepticus in adults: a systematic review and meta-analysis.

AIM: Status epilepticus (SE) is a life-threatening neurological emergency. There is insufficient evidence regarding which antiepileptic therapy is most effective in patients with benzodiazepine-refractory convulsive SE. Therefore, this study aimed to evaluate intravenous phenytoin (PHT) and other intravenous antiepileptic medications for SE. METHODS: We searched PubMed, the Cochrane Central Register of Controlled Trials, and Igaku Chuo Zasshi for published randomized controlled trials (RCTs) in humans up to August 2019. We compared outcomes between intravenous PHT and other intravenous medications. The important primary composite outcomes were the successful clinical cessation of seizures, mortality, and neurological outcomes at discharge. The reliability of the level of evidence for each outcome was compared using the Grading of Recommendations Assessment, Development, and Evaluation approach. RESULTS: A total of 1,103 studies were identified from the databases, and 10 RCTs were included in the analysis. The ratio of successful clinical seizure cessation was significantly lower (risk ratio [RR] 0.89; 95% confidence interval [CI], 0.82-0.97) for patients treated with intravenous PHT than with other medications. When we compared mortality and neurological outcomes at discharge, we observed no significant differences between patients treated with PHT and those treated with other medications. The RRs were 1.07 (95% CI, 0.55-2.08) and 0.91 (95% CI, 0.72-1.15) for mortality and neurological outcomes at discharge, respectively. CONCLUSIONS: Our findings showed that intravenous PHT was significantly inferior to other medications in terms of the cessation of seizures. No significant differences were observed in mortality or neurological outcomes between PHT and other medications.

Impact of the COVID-19 pandemic on a trauma center of a university hospital in Japan.

BACKGROUND: The Coronavirus disease 2019 pandemic caused the Japanese government to declare a State of Emergency on April 7, 2020. The aim of this study is to provide an overview of the effects of the pandemic on surgical cases at a university hospital trauma center. METHODS: An observational study was performed at a trauma center in a tertiary hospital in Tokyo, Japan. The number of surgeries was compared between two periods: a historical control period (Tuesday April 9 to Monday May 27, 2019) and the period of the Japan State of Emergency due to COVID-19 (Tuesday April 7-Monday May 25, 2020). Information on patient age, gender, and surgical diagnosis, site, and procedure was collected for cases operated on in each period. The number of trauma surgeries was compared between the two periods. Data from the two periods were compared statistically. RESULTS: The total number of surgical cases was 151 in the control period and 83 in the COVID-19 period (including no cases with COVID-19), a decrease of 45.0%. There were significantly more surgeries for patients with hip fractures in the COVID-19 period (9 vs. 19, P < 0.001 by Fisher exact test). CONCLUSIONS: During the State of Emergency in Japan, the number of operations for trauma patients at the trauma center decreased, but surgeries for hip fracture increased.

Association between active cooling and lower mortality among patients with heat stroke and heat exhaustion.

Body cooling is recommended for patients with heat stroke and heat exhaustion. However, differences in the outcomes of patients who do or do not receive active cooling therapy have not been determined. The best available evidence supporting active cooling is based on a case series without comparison groups; thus, the effectiveness of this method in improving patient prognoses cannot be appropriately quantified. Therefore, we compared the outcomes of heat stroke patients receiving active cooling with those of patients receiving rehydration-only therapy. This prospective observational multicenter registry-based study of heat stroke and heat exhaustion patients was conducted in Japan from 2010 to 2019. The patients were stratified into the "severe" group or the "mild-to-moderate" group, per clinical findings on admission. After conducting multivariate logistic regression analyses, we compared the prognoses between patients who received "active cooling + rehydration" and patients who received "rehydration only," with in-hospital death as the endpoint. Sex, age, onset situation (i.e., exertional or non-exertional), core body temperature, liver damage, renal dysfunction, and disseminated intravascular coagulation were considered potential covariates. Among those who received active cooling and rehydration-only therapy, the in-hospital mortality rates were 21.5% and 35.5%, respectively, for severe patients (n = 231) and 3.9% and 5.7%, respectively, for mild-to-moderate patients (n = 578). Rehydration-only therapy was associated with a higher in-hospital mortality in patients with severe heat illness (adjusted odds ratio [aOR], 3.29; 95% confidence interval [CI], 1.21-8.90), whereas the cooling methods were not associated with lower in-hospital mortality in patients with mild-to-moderate heat illness (aOR, 2.22; 95% CI, 0.92-5.84). Active cooling was associated with lower in-hospital mortality only in the severe group. Our results indicated that active cooling should be recommended as an adjunct to rehydration-only therapy for patients with severe heat illness.

Evaluation of factors related to overdose in patients with impaired consciousness who are transported by emergency medical services: an age-specific research.

BACKGROUND: Drug overdose accounts for most of the admissions to the emergency department. Prescription drugs, most of which are psychotropic medications, are often misused for drug overdose. The purpose of this study was to investigate the association between overdose in patients transported with disorders of consciousness and psychotropic medications administered prior to transport, so as to enable quick differentiation of drug overdose patients from patients with disorders of consciousness. METHODS: We evaluated 222 patients transported to the Advanced Critical Care Center of Teikyo University Hospital due to disorders of consciousness. The patients were categorized into two groups: overdose group (n = 128) and control group with other disorders of consciousness (n = 94). Logistic regression models were used to assess the association between disorders of consciousness due to drug overdose and psychotropic drugs prescribed before emergency transportation based on sex and age. RESULTS: According to multivariate logistic regression analysis, only female sex (odds ratio [OR] 4.54, 95% confidence interval [CI] 2.43-8.05, P < 0.0001) was associated with overall overdose. Results from the univariate logistic regression analysis showed that in the group of patients aged 40-50 years, female sex (OR 4.36, 95% CI; 1.54-12.4, P = 0.006) and the use of psychotropic drugs (OR 5.05, 95% CI; 1.75-14.6, P = 0.003), benzodiazepines (OR 4.64, 95% CI; 1.61-13.4, P < 0.05), antidepressants (OR 11.4, 95% CI; 2.35-55.8, P = 0.003), and anticonvulsants (OR 4.46, 95% CI; 1.11-17.9, P = 0.035) were associated with overdose. According to multivariate logistic regression analysis, female sex (OR 4.44, 95% CI; 1.37-14.3, P = 0.013) and antidepressants (OR 7.95, 95% CI; 1.21-52.1, P = 0.031) were associated with overdose patients aged 40-50 years. CONCLUSIONS: As a reference in distinguishing overdose in women in their 40s and 50s who present with impaired consciousness, attention may need to be paid to the type of psychotropic drug used, especially antidepressants.

[FOURNIER GANGRENE: AN ANALYSIS OF 15 CASES].

(Objectives) This study aimed to evaluate the clinical characteristics and the mortality risk factors of 15 patients with Fournier gangrene in the past decade at Teikyo University Hospital. (Materials and methods) We retrospectively assessed 15 patients with Fournier gangrene between May 2009 and April 2019. We compared the demographic characteristics along with several clinical variables including Fournier Gangrene Severity Index of the survivors and nonsurvivors. We also assessed the risk factors associated with mortality. (Results) All patients were men with a median age of 67 years. Among the 15 patients, 9 had diabetes mellitus (60%). Furthermore, 14 patients (93%) underwent surgical debridement, 5 (33%) required orchiectomy, 3 (20%) were treated with cystostomy for urinary diversion, and 3 (20%) needed temporary colostomy for fecal diversion. Three patients died of the disease with a mortality rate of 20%. The nonsurvivors were significantly older (p = 0.043) and had a smaller body mass index (p = 0.038) than the survivors. The scores of clinical risk models, such as the Fournier Gangrene Severity Index, were higher in nonsurvivors than in survivors, with no statistical significance presumably due to the small sample size. (Conclusions) The mortality rate for Fournier gangrene during the past decade at our institution was 20%. Fournier gangrene was a potentially fatal disease even in the 2010s.

Prospective evaluation of the "Stop the Bleed" program in Japanese participants.

BACKGROUND: The Stop the Bleed (STB) program was developed to bring military bleeding control techniques into wider use among American civilians. It was introduced in Japan in case of mass casualty events during the Tokyo Olympic/Paralympic Games in 2021, and its effectiveness was prospectively evaluated. METHODS: Japanese physicians certified as STB instructors held bleeding control basic training courses from April to July 2019. Participants' knowledge was assessed using pre-training and post-training tests comprising five questions. One point was awarded for each correct answer, giving a maximum total score of 5. (Q1) What is the most common preventable trauma death?; (Q2) Which actions should be prioritized for bleeding victims?; (Q3) Which patients should be transferred to hospital first?; (Q4) How should a tourniquet be applied?; (Q5) How should pain associated with a tourniquet be managed? RESULTS: The study involved 157 participants (20 physicians/nurses, 82 medical students, 33 emergency services personnel, 22 police officers/security personnel). The mean±SD scores were 2.1±1.1 before training and 3.2±1.0 after training (p<0.01). The respective percentages of correct answers before and after training were 58% and 75% for Q1, 10% and 13% for Q2, 38% and 55% for Q3, 73% and 89% for Q4, and 33% and 91% for Q5. Q2 had the lowest percentage of correct answers and the poorest improvement. DISCUSSION: The STB program improved tourniquet knowledge. However, it was less effective in improving knowledge about which actions to prioritize for bleeding victims. This may be because the participants were well trained in basic life support and therefore expected to immediately commence cardiopulmonary resuscitation for patients in shock. The STB program is valuable in preparing Japanese people for mass casualty events during the Tokyo Olympic/Paralympic Games in 2021. LEVEL OF EVIDENCE: IV. STUDY TYPE: Therapeutic.

Clinical characteristics, prognostic factors, and outcomes of heat-related illness (Heatstroke Study 2017-2018).

AIM: Heat-related illness is common, but its epidemiology and pathological mechanism remain unclear. The aim of this study was to report current clinical characteristics, prognostic factors, and outcomes of heat-related illness in Japan. METHODS: We undertook a prospective multicenter observational study in Japan. Only hospitalized patients with heat-related illness were enrolled from 1 July to 30 September 2017 and 1 July to 30 September 2018. RESULTS: A total of 763 patients were enrolled in the study. Median age was 68 years (interquartile range, 49-82 years) and median body temperature on admission was 38.2°C (interquartile range, 36.8-39.8°C). Non-exertional cause was 56.9% and exertional cause was 40.0%. The hospital mortality was 4.6%. The median Japanese Association for Acute Medicine disseminated intravascular coagulation (JAAM DIC), Sequential Organ Failure Assessment (SOFA), and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores on admission were 1 (0-2), 4 (2-6), and 13 (8-22), respectively. To predict hospital mortality, areas under the receiver operating characteristic curves were 0.776 (JAAM DIC score), 0.825 (SOFA), and 0.878 (APACHE II). There were 632 cases defined as heatstroke by JAAM heat-related illness criteria, 73 cases diagnosed as having DIC. A total of 16.6% patients had poor neurological outcome (modified Rankin Scale ≥ 4) at hospital discharge. In the multivariate analysis, Glasgow Coma Scale and platelets were independent predictors of mortality. Type of heatstroke, Glasgow Coma Scale, and platelets were independent predictors of poor neurological outcome. Body temperature was not associated with mortality or poor neurological outcome. CONCLUSIONS: In this study, hospital mortality of heat-related illness was <5%, one-sixth of the patients had poor neurological outcome. The APACHE II, SOFA, and JAAM DIC scores predicted hospital mortality. Body temperature was not associated with mortality or poor neurological outcome.

Relationship Between Institutional Volume of Out-of-Hospital Cardiac Arrest Cases and 1-Month Neurologic Outcomes: A Post Hoc Analysis of a Prospective Observational Study.

BACKGROUND: The influence of institutional volume of out-of-hospital cardiac arrest (OHCA) cases on outcomes remains unclear. OBJECTIVES: This study evaluated the relationship between institutional volume of adult, nontraumatic OHCA cases and 1-month favorable neurologic outcomes. METHODS: This study retrospectively analyzed data between January 2012 and March 2013 from a prospective observational study in the Kanto area of Japan. We analyzed adult patients with nontraumatic OHCA who underwent cardiopulmonary resuscitation by emergency medical service personnel and in whom spontaneous circulation was restored. Based on the institutional volume of OHCA cases, we divided institutions into low-, middle-, or high-volume groups. The primary and secondary outcomes were 1-month favorable neurologic outcomes and 1-month survival, respectively. A multivariate logistic regression analysis adjusted for propensity score and in-hospital variables was performed. RESULTS: Of 2699 eligible patients, 889, 898, and 912 patients were transported to low-volume (40 institutions), middle-volume (14 institutions), and high-volume (9 institutions) centers, respectively. Using low-volume centers as the reference, transport to a middle- or high-volume center was not significantly associated with a favorable 1-month neurologic outcome (adjusted odds ratio [OR] 1.21 [95% confidence interval {CI} 0.84-1.75] and adjusted OR 0.77 [95% CI 0.53-1.12], respectively) or 1-month survival (adjusted OR 1.10 [95% CI 0.82-1.47] and adjusted OR 0.76 [95% CI 0.56-1.02], respectively). CONCLUSIONS: Institutional volume was not significantly associated with favorable 1-month neurologic outcomes or 1-month survival in OHCA. Further investigation is needed to determine the association between hospital characteristics and outcomes in patients with OHCA.

Emergency intensive care unit pharmacist's intervention may reduce time to four-factor prothrombin complex concentrate administration: a retrospective study.

BACKGROUND: Four-factor prothrombin complex concentrate (4F-PCC) must be administered as soon as possible, and in our emergency intensive care unit (EICU), pharmacists are available on weekdays for consultation on expediting 4F-PCC administration. Although recent reports have described a reduction in time to 4F-PCC administration, few studies have addressed if this is because of EICU pharmacist's intervention, and there are no such studies in Japan. Therefore, we aimed to examine whether EICU pharmacist's intervention reduced time to 4F-PCC administration. METHODS: This single-center retrospective cohort study was conducted from December 2017 to May 2019. We enrolled patients who received 4F-PCC due to major bleeding or requirement of urgent surgical/invasive procedures (n = 10). Patients were divided into two groups, namely, the intervention group (n = 5), in which EICU pharmacists consulted on weekdays, and the nonintervention group (n = 5), in which an intervention was not possible because of the absence of the EICU pharmacist. RESULTS: The median time from patient presentation to the EICU to 4F-PCC administration (103 min vs. 111 min, p = 0.4) was similar between the two groups; however, the median time from 4F-PCC prescription ordering to administration was significantly shorter in the intervention group than in the nonintervention group (21 min vs. 60 min, p = 0.02). CONCLUSIONS: EICU pharmacist's intervention improves the process from 4F-PCC prescription to administration and can reduce time to 4F-PCC administration.