Long-term outcomes of patients evacuated from hospitals near the Fukushima Daiichi nuclear power plant after the Great East Japan Earthquake.

INTRODUCTION: After the accident of the Fukushima Daiichi nuclear power plant due to the Great East Japan Earthquake in March 2011, the Japanese government issued a mandatory evacuation order for people living within a 20 km radius of the nuclear power plant. The aim of the current study was to investigate long-term outcomes of these patients and identify factors related to mortality. MATERIALS AND METHODS: Patients who were evacuated from hospitals near the Fukushima Daiichi nuclear power plant to the Aizu Chuo Hospital from 15 to 26 March, 2011 were included in this study. The following data were collected from medical records: age, sex, activities of daily life, hospital they were admitted in at the time of earthquake, distance between the facility and the nuclear power plant, reasons of evacuation and number of transfers. The patient outcomes were collected from medical records and/or investigated on the telephone in January 2012. RESULTS: A total of 97 patients (28 men and 69 women) were transferred from 10 hospitals via ambulances or buses. No patients died or experienced exacerbation during transfer. Median age of the patients was 86 years. Of the total, 36 patients were not able to obey commands, 44 were bed-ridden and 61 were unable to sustain themselves via oral intake of food. Among 86 patients who were followed-up, 41 (48%) died at the end of 2011. Multiple-regression analysis showed that non-oral intake [Hazard Ratio (HR): 6.07, 95% Confidence interval (CI): 1.94-19.0] and male sex [HR: 8.35, 95% CI: 2.14-32.5] had significant impact on mortality. CONCLUSION: This study found that 48% of the evacuated patients died 9 months after the earthquake and they had significantly higher mortality rate than the nursing home residents. Non-oral intake and male sex had significant impact on mortality. These patients should be considered as especially vulnerable in case of hospital evacuation.

Prompt Procedures Have a Great Impact on the Consequences of Asiatic Black Bear Mauling.

INTRODUCTION: Although bear-inflicted human injuries are rare and the mortality rate of the injuries is usually not high, the chances of bear-human interactions have been increasing, with fatal cases being reported in Japan every year. The aim of this study was to report a series of bear-inflicted injuries and discuss their management and severity. MATERIALS AND METHODS: A retrospective study was performed at the emergency and critical care center of Aizu Chuo Hospital, a tertiary care center in Japan, from May 2013 to September 2015. During this period, we encountered 14 black bear injury patients (12 men and 2 women). RESULTS: Six victims were attacked in dense forests while collecting wild vegetables; 4 victims were attacked near their houses. Lacerations of the scalp and face were the most frequent injuries, affecting 13 patients. Three patients developed hemorrhagic shock. Injury severity scores ranged from 2 to 12 (median value, 6). None of the injuries was fatal. Thirteen patients were transported by the local fire department's ambulances, 9 of whom were transferred to doctor ambulances. CONCLUSIONS: Although the severity and mortality rate following bear-inflicted injuries are not high, these encounters usually take place in remote rural areas, so a delay in rescue and proper care can lead to the incident becoming fatal. Hence, early decisions and arrangements for patient transportation to a tertiary care center and prompt measures to save lives will have a positive impact on the consequences of such incidents.

Effect of a selective neutrophil elastase inhibitor on mortality and ventilator-free days in patients with increased extravascular lung water: a post hoc analysis of the PiCCO Pulmonary Edema Study.

BACKGROUND: Neutrophil elastase plays an important role in the development and progression of acute respiratory distress syndrome (ARDS). Although the selective elastase inhibitor, sivelestat, is widely used in Japan for treating ARDS patients, its effectiveness remains controversial. The aim of the current study was to investigate the effects of sivelestat in ARDS patients with evidence of increased extravascular lung water by re-analyzing a large multicenter study database. METHODS: A post hoc analysis of the PiCCO Pulmonary Edema Study was conducted. This multicenter prospective cohort study included 23 institutions in Japan. Adult mechanically ventilated ARDS patients with an extravascular lung water index of >10 mL/kg were included and propensity score analyses were performed. The endpoints were 28-day mortality and ventilator-free days (VFDs). RESULTS: Patients were categorized into sivelestat (n = 87) and control (n = 77) groups, from which 329 inverse probability-weighted group patients (162 vs. 167) were generated. The overall 28-day mortality was 31.1% (51/164). There was no significant difference in 28-day mortality between the study groups (sivelestat vs. control; unmatched: 29.9% vs. 32.5%; difference, -2.6%, 95% confidence interval (CI), -16.8 to 14.2; inverse probability-weighted: 24.7% vs. 29.5%, difference, -4.8%, 95% CI, -14.4 to 9.6). Although administration of sivelestat did not alter the number of ventilator-free days (VFDs) in the unmatched (9.6 vs. 9.7 days; difference, 0.1, 95% CI, -3.0 to 3.1), the inverse probability-weighted analysis identified significantly more VFDs in the sivelestat group than in the control group (10.7 vs. 8.4 days, difference, -2.3, 95% CI, -4.4 to -0.2). CONCLUSIONS: Although sivelestat did not significantly affect 28-day mortality, this treatment may have the potential to increase VFDs in ARDS patients with increased extravascular lung water. Prospective randomized controlled studies are required to confirm the results of the current study.

Early-phase changes of extravascular lung water index as a prognostic indicator in acute respiratory distress syndrome patients.

BACKGROUND: The features of early-phase acute respiratory distress syndrome (ARDS) are leakage of fluid into the extravascular space and impairment of its reabsorption, resulting in extravascular lung water (EVLW) accumulation. The current study aimed to identify how the initial EVLW values and their change were associated with mortality. METHODS: This was a post hoc analysis of the PiCCO Pulmonary Edema Study, a multicenter prospective cohort study that included 23 institutions. Single-indicator transpulmonary thermodilution-derived EVLW index (EVLWi) and conventional prognostic factors were prospectively collected over 48 h after enrollment. Associations between 28-day mortality and each variable including initial (on day 0), mean, maximum, and Δ (subtracting day 2 from day 0) EVLWi were evaluated. RESULTS: We evaluated 192 ARDS patients (median age, 69 years (quartile, 24 years); Sequential Organ Failure Assessment (SOFA) score on admission, 10 (5); all-cause 28-day mortality, 31%). Although no significant differences were found in initial, mean, or maximum EVLWi, Δ-EVLWi was significantly higher (i.e., more reduction in EVLWi) in survivors than in non-survivors (3.0 vs. -0.3 mL/kg, p = 0.006). Age, maximum, and Δ-SOFA scores and Δ-EVLW were the independent predictors for survival according to the Cox proportional hazard model. Patients with Δ-EVLWi > 2.8 had a significantly higher incidence of survival than those with Δ-EVLWi ≤ 2.8 (log-rank test, χ (2) = 7.08, p = 0.008). CONCLUSIONS: Decrease in EVLWi during the first 48 h of ARDS may be associated with 28-day survival. Serial EVLWi measurements may be useful for understanding the pathophysiologic conditions in ARDS patients. A large multination confirmative trial is required.

Quantitative diagnosis of diffuse alveolar damage using extravascular lung water.

OBJECTIVES: Acute respiratory distress syndrome is characterized by diffuse alveolar damage and increased extravascular lung water levels. However, there is no threshold extravascular lung water level that can indicate diffuse alveolar damage in lungs. We aimed to determine the threshold extravascular lung water level that discriminates between normal lungs and lungs affected with diffuse alveolar damage. DESIGN: A retrospective analysis of normal lungs and lungs affected with diffuse alveolar damage was performed. SETTING: Normal lung cases were taken from published data. Lung cases with diffuse alveolar damage were taken from a nationwide autopsy database. All cases of autopsy followed hospital deaths in Japan from more than 800 hospitals between 2004 and 2009; complete autopsies with histopathologic examinations were performed by board-certified pathologists authorized by the Japanese Society of Pathology. PATIENTS: Normal lungs: 534; lungs with diffuse alveolar damage: 1,688. INTERVENTIONS: We compared the postmortem weights of both lungs between the two groups. These lung weights were converted to extravascular lung water values using a validated equation. Finally, the extravascular lung water value that indicated diffuse alveolar damage was estimated using receiver operating characteristic analysis. MEASUREMENTS AND MAIN RESULTS: The extravascular lung water values of the lungs showing diffuse alveolar damage were approximately two-fold higher than those of normal lungs (normal group, 7.3±2.8 mL/kg vs diffuse alveolar damage group 13.7±4.5 mL/kg; p<0.001). An extravascular lung water level of 9.8 mL/kg allowed the diagnosis of diffuse alveolar damage to be established with a sensitivity of 81.3% and a specificity of 81.2% (area under the curve, 0.90; 95% CI, 0.88-0.91). An extravascular lung water level of 14.6 mL/kg represented a 99% positive predictive value. CONCLUSIONS: This study may provide the first validated quantitative bedside diagnostic tool for diffuse alveolar damage. Extravascular lung water may allow the detection of diffuse alveolar damage and may support the clinical diagnosis of acute respiratory distress syndrome. The best extravascular lung water cut-off value to discriminate between normal lungs and lungs with diffuse alveolar damage is around 10 mL/kg.

Implementation of the fifth link of the chain of survival concept for out-of-hospital cardiac arrest.

BACKGROUND: The American Heart Association 2010 resuscitation guidelines recommended adding a fifth link (multidisciplinary postresuscitation care in a regional center) to the previous 4 in the chain of survival concept for out-of-hospital cardiac arrest. Our study aimed to determine the effectiveness of this fifth link. METHODS AND RESULTS: This multicenter prospective cohort study involved all eligible out-of-hospital cardiac arrest patients in the Aizu region (n=1482, suburban/rural, Fukushima, Japan). Proportions of favorable neurological outcomes were evaluated before (January 2006-April 2008) and after (January 2009-December 2010) the implementation of the fifth link. After implementation, all patients were transported directly from the field to the tertiary-level hospital or secondarily from an outlying hospital to the tertiary-level hospital after restoration of circulation. The tertiary hospital provided intensive postresuscitation care, including appropriate hemodynamic and respiratory management, therapeutic hypothermia, and percutaneous coronary intervention. One-month survival with a favorable neurological outcome among all patients treated by emergency medical services providers improved significantly after implementation (4 of 770 [0.5%] versus 21 of 712 [3.0%]; P<0.001). The adjusted odds ratios of favorable neurological outcome were 0.9 (95% confidence interval, 0.7-1.1) for early access to emergency medical care, 3.1 (95% confidence interval, 0.7-14.2) for bystander resuscitation, 14.7 (95% confidence interval, 3.2-67.0) for early defibrillation, 1.0 (95% confidence interval, 1.0-1.1) for early advanced life support, and 7.8 (95% confidence interval, 1.6-39.0) for the fifth link. CONCLUSION: The proportion of out-of-hospital cardiac arrest patients with a favorable neurological outcome improved significantly after the implementation of the fifth link, which may be an independent predictor of outcome. CLINICAL TRIAL REGISTRATION: URL: http://www.apps.who.int/trialsearch. Unique identifier: UMIN000001607.

Disseminated aspergillosis associated with tsunami lung.

Many survivors of the tsunami that occurred following the Great East Japan Earthquake on March 11, 2011, contracted a systemic disorder called "tsunami lung," a series of severe systemic infections following aspiration pneumonia caused by near drowning in the tsunami. Generally, the cause of aspiration pneumonia is polymicrobial, including fungi and aerobic and anaerobic bacteria, but Aspergillus infection is rarely reported. Here we report a case of tsunami lung complicated by disseminated aspergillosis, as diagnosed during autopsy.

Plasma neutrophil elastase correlates with pulmonary vascular permeability: a prospective observational study in patients with pneumonia.

BACKGROUND AND OBJECTIVE: Little is known about plasma neutrophil elastase (PNE) levels in patients with community-acquired pneumonia (CAP) requiring treatment in the intensive care unit (ICU) or high care unit (HCU). In addition, the influence of PNE on pulmonary vascular permeability in a clinical setting has not been investigated. The aims of this study were (i) to investigate PNE levels in patients with CAP and (ii) to explore the relationship between PNE and pulmonary vascular permeability. METHODS: Fourteen consecutive CAP patients who were admitted to the HCU (n = 8) or ICU (n = 6) were prospectively investigated over a 6-month period. A group of eight patients with hydrostatic pulmonary oedema without CAP served as a control group (CG). PNE levels were measured at regular intervals. The pulmonary vascular permeability index (PVPI) was monitored in all ICU and CG patients, using the PiCCO system. RESULTS: PNE levels were higher in the CAP patients (132 (84-261) ng/mL) than in the CG patients (77 (64-107) ng/mL) (P = 0.04), and were highest in the ICU patients (186 (75-466) ng/mL). The PVPI was higher in the ICU patients (2.85 (1.90-4.00)) than in the CG patients (1.15 (0.75-2.35)) (P = 0.02). PNE levels correlated with PVPI in the ICU patients (r = 0.81, P < 0.001) but there was no correlation among the CG patients (r = 0.14, P = 0.73). CONCLUSIONS: Patients with severe CAP had high levels of PNE, which was closely correlated with PVPI. PNE may be involved in the pathogenesis of severe pneumonia.

Validation of extravascular lung water measurement by single transpulmonary thermodilution: human autopsy study.

INTRODUCTION: Gravimetric validation of single-indicator extravascular lung water (EVLW) and normal EVLW values has not been well studied in humans thus far. The aims of this study were (1) to validate the accuracy of EVLW measurement by single transpulmonary thermodilution with postmortem lung weight measurement in humans and (2) to define the statistically normal EVLW values. METHODS: We evaluated the correlation between pre-mortem EVLW value by single transpulmonary thermodilution and post-mortem lung weight from 30 consecutive autopsies completed within 48 hours following the final thermodilution measurement. A linear regression equation for the correlation was calculated. In order to clarify the normal lung weight value by statistical analysis, we conducted a literature search and obtained the normal reference ranges for post-mortem lung weight. These values were substituted into the equation for the correlation between EVLW and lung weight to estimate the normal EVLW values. RESULTS: EVLW determined using transpulmonary single thermodilution correlated closely with post-mortem lung weight (r = 0.904, P < 0.001). A linear regression equation was calculated: EVLW (mL) = 0.56 × lung weight (g) - 58.0. The normal EVLW values indexed by predicted body weight were approximately 7.4 ± 3.3 mL/kg (7.5 ± 3.3 mL/kg for males and 7.3 ± 3.3 mL/kg for females). CONCLUSIONS: A definite correlation exists between EVLW measured by the single-indicator transpulmonary thermodilution technique and post-mortem lung weight in humans. The normal EVLW value is approximately 7.4 ± 3.3 mL/kg. TRIAL REGISTRATION: UMIN000002780.