STSS by Streptococcus pyogenes emm22 genotype accompanied by CsrS mutation: A case report.

The patient was a 22-year-old woman with no comorbidities who was transferred to our hospital due to cardiac arrest. Treatment enabled return to spontaneous circulation in the patient before arriving at the hospital. At the hospital, the patient's vital signs were unstable. Vasopressors and hyperhydration therapy were administered. Computed Tomography (CT) showed no remarkable change that caused the cardiac arrest. Antibiotics were prescribed after a blood culture exam. The patient was admitted to the ICU. In the ICU, the high-capacity vasopressors, hyperhydration therapy and transfusion of fresh frozen plasma were continued. Two hours after examining the blood culture, the results remained positive. Gram staining revealed Streptococcus, and the antibiotics were switched to penicillin G potassium, clindamycin and immunoglobulin was added. Hyperhydration therapy caused respiratory failure. Ten hours after admission to the ICU, extracorporeal membrane oxygenation was introduced, but the patient's general status did not improve. The patient died at 40 hours after admission. Blood culture results proved Streptococcus pyogenes; T and M serotypes were unclassifiable. The emm genotype was emm22. Regarding fever toxin genes, speA and speB were positive, and speC was negative. Among CsrS, CsrR and Rgg amino acid sequences, mutations in CsrS were detected.

Impact of missing values on the ability of the acute physiology and chronic health evaluation III and Japan risk of death models to predict mortality.

PURPOSE: This study assessed model performance of the Acute Physiology and Chronic Health Evaluation (APACHE) III and Japan Risk of Death (JROD) when degraded by the number and category of missing variables. We also examined the impact of missing data on predicted mortality for facilities with missing physiological variables. METHODS: We obtained data from the Japanese Intensive care PAtient Database (JIPAD). We calculated observed and predicted mortality rates using the APACHE III and JROD and the standardized mortality ratio (SMR) by the number and category of missing variables. Smoothed spline curves were calculated for the SMR to the missing proportion of the facility. RESULTS: A total of 61,357 patients from 57 ICUs were included between April 2015 and March 2019. The APACHE III and JROD SMRs increased as the number of missing values increased. The SMR in the APACHE III model was elevated in facilities with a larger proportion of missing in each of the APS categories, arterial blood gas, albumin, glucose, and bilirubin. Facilities with a high proportion of missing albumin data preserved their SMRs in only the JROD model. CONCLUSION: An increased number of missing physiological variables resulted in falsely low predicted mortality rates and high SMRs.

Impact of physician-staffed ground emergency medical services-administered pre-hospital trauma care on in-hospital survival outcomes in Japan.

PURPOSE: In Japan, the vehicle used in pre-hospital trauma care systems with physician-staffed ground emergency medical services (GEMS) is referred to as a "doctor car". Doctor cars are highly mobile physician-staffed GEMS that can provide complex pre-hospital trauma management using various treatment strategies. The number of doctor car operations for patients with severe trauma has increased. Considering facility factors, the association between doctor cars and patient outcomes remains unclear. Therefore, this study aimed to examine the relationship between doctor cars for patients with severe trauma and survival outcomes in Japan. METHODS: A nationwide retrospective cohort study was conducted to compare the impact of the doctor car group with the non-physician-staffed GEMS group on in-hospital survival in adult patients with severe trauma. The data were analyzed using multivariable logistic regression models with generalized estimating equations. RESULTS: This study included 372,365 patients registered in the Japan Trauma Data Bank between April 2009 and March 2019. Of the 49,144 eligible patients, 2361 and 46,783 were classified into the doctor car and non-physician staffed GEMS groups, respectively. The adjusted odds ratio (OR) for survival was significantly higher in the doctor car group than in the non-physician staffed GEMS group (adjusted OR = 1.228 [95% confidence interval 1.065-1.415]). CONCLUSION: Using nationwide data, this novel study suggests that doctor cars improve the in-hospital survival rate of patients with severe trauma in Japan. Therefore, doctor cars could be an option for trauma strategies.

Evacuation at Home Delayed the First Medical Intervention in Minamisanriku Town after the 2011 Great East Japan Earthquake.

INTRODUCTION: In Japan, evacuation at home is expected to increase in the future as a post-disaster evacuation type due to the pandemic, aging, and diverse disabilities of the population. However, more disaster-related indirect deaths occurred in homes than in evacuation centers after the 2011 Great East Japan Earthquake (GEJE). The health risks faced by evacuees at home have not been adequately discussed. STUDY OBJECTIVE: This study aimed to clarify the gap in disaster health management for evacuees at home compared to the evacuees at the evacuation centers in Minamisanriku Town, which lost all health care facilities after the 2011 GEJE. METHODS: This was a retrospective cross-sectional and quasi-experimental study based on the anonymized disaster medical records (DMRs) of patients from March 11 through April 10, 2011, that compared the evacuation-at-home and evacuation-center groups focusing on the day of the first medical intervention after the onset. Multivariable Cox regression analysis and propensity score (PS)-matching analysis were performed to identify the risk factors and causal relationship between the evacuation type and the delay of medical intervention. RESULTS: Of the 2,838 eligible patients, 460 and 2,378 were in the evacuation-at-home and evacuation-center groups, respectively. In the month after the onset, the evacuation-at-home group had significantly lower rates of respiratory and mental health diseases than the evacuation-center group. However, the mean time to the first medical intervention was significantly delayed in the evacuation-at-home group (19.3 [SD = 6.1] days) compared to that in the evacuation-center group (14.1 [SD = 6.3] days); P <.001). In the multivariable Cox regression analysis, the hazard ratio (HR) of delayed medical intervention for evacuation-at-home was 2.31 with a 95% confident interval of 2.07-2.59. The PS-matching analysis of the adjusted 459 patients in each group confirmed that evacuation at home was significantly associated with delays in the first medical intervention (P <.001). CONCLUSION: This study suggested, for the first time, the causal relationship between evacuation at home and delay in the first medical intervention by PS-matching analysis. Although evacuation at home had several advantages in reducing the frequencies of some diseases, the delay in medical intervention could exacerbate the symptoms and be a cause of indirect death. As more evacuees are likely to remain in their homes in the future, this study recommends earlier surveillance and health care provision to the home evacuees.

Analysis of Disaster-Related Deaths in the Great East Japan Earthquake: A Retrospective Observational Study Using Data from Ishinomaki City, Miyagi, Japan.

Disaster-related deaths are of two types: direct and indirect. Preventable disaster-related deaths reported in the Great East Japan Earthquake (GEJE) included a large number of indirect deaths. This study aimed to investigate the data on disaster-related deaths in the GEJE in Ishinomaki City, Miyagi Prefecture, and to clarify the scope of disaster-related deaths to help future disaster preparedness. A retrospective observational study was conducted using public data on disaster-related deaths from March 2011 to January 2021, available at Ishinomaki City Hall. Descriptive and Cox regression analyses were conducted. The most common direct cause of disaster-related deaths was respiratory diseases, which were more common among those aged less than three months and over 60 years. Suicide was common among those aged under 60 years, and the proportion increased more than six months after the disaster. The risk of death was significantly higher among those who needed nursing care than among those independent in daily living. The results indicate that measures should be taken for the elderly and those who need care from an early phase after the disaster. The analysis of data on disaster-related deaths in other affected municipalities may provide further evidence to help reduce disaster-related deaths.

Two Cases of Intrafamilial Transmission of Community-Acquired Methicillin-Resistant Staphylococcus aureus Producing Both PVL and TSST-1 Causing Fatal Necrotizing Pneumonia and Sepsis.

INTRODUCTION: Staphylococcus aureus produces numerous toxins, such as toxic shock syndrome toxin 1 (TSST-1) and Panton-Valentine leukocidin (PVL). We isolated community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) strains producing both TSST-1 and PVL isolated from severe necrotizing pneumonia cases in a Nepali family. Detection of these CA-MRSA strains is rare in the world, and infection with these strains can take a rapidly progressive and lethal course. In this study, we traced the clinical course of this case and conducted a genetic analysis of the isolated strains. CASE REPORT: We described 2 familial cases (a 20-year-old male and 61-year-old female) of severe necrotizing pneumonia caused by CA-MRSA with the TSST-1 and PVL genes. A 20-year-old Nepalese male was admitted to our hospital after a 3-day history of high fever and coughing. Despite resuscitation efforts, he died of multiple organ failure. A 61-year-old Nepalese female was admitted to our hospital with a complaint of high fever and dyspnea for 1 day. She was the grandmother of the male subject and mostly stayed at his residence in Japan. We administered intravenous antibiotics, including anti-MRSA antibiotics, and she improved in 2 weeks. The sequence type of the isolates was ST22/SCCmec type IVa, and the spa type was t005. The virulence genes detected were as follows: PVL gene (lukSF-pv), TSST-1 gene (tst-1), sec, seg, sei, sel, sem, sen, seo, and seu. ST22 was not the dominant CA-MRSA clone type in Japan. Some of the reports demonstrated that PVL-/TSST-1-positive ST22-MRSA strains are prevalent in Nepal. Therefore, the MRSA strains were thought to be acquired from Nepal. CONCLUSION: These cases highlight the emergence of TSST-1- and PVL-positive CA-MRSA infection and its association with life-threatening community-acquired necrotizing pneumonia. Clinicians should note the possibility of introducing MRSA strains from abroad and be aware of this illness to initiate appropriate treatment.

[Antidote update].

In Japan, several products of the antidote for poisoning have been authorized in clinical use from some recent years. For example, Hydroxcobalamin for cyanide poisoning was introduced in 2008. In 2009, Ministry of Health, Labour and Welfare invited suggestions of demand of pharmaceutical products which is high in the need in the medical care but yet unauthorized. Japanese Society for Clinical Toxicology and Japan Poison Information Center applied some candidates including methyleneblue (MB) and fomepizole, both of them were authorized in clinical market in 2015. MB is the medicine for methemoglobinemia, caused by variety of chemical products such as nitrogen oxide. Fomepizole is the antidote for methanol and ethyleneglycol, blocking alcohol dehydrogenase.

Investigation and treatment of pulmonary embolism as a potential etiology may be important to improve post-resuscitation prognosis in non-shockable out-of-hospital cardiopulmonary arrest: report on an analysis of the SOS-KANTO 2012 study.

Background: The prognosis of non-shockable out-of-hospital cardiac arrest is worse than that of shockable out-of-hospital cardiac arrest. We investigated the associations between the etiology and prognosis of non-shockable out-of-hospital cardiac arrest patients who experienced the return of spontaneous circulation after arriving at hospital. Methods and Results: All subjects were extracted from the SOS-KANTO 2012 study population. The subjects were 3,031 adults: (i) who had suffered out-of-hospital cardiac arrest, (ii) for whom there were no pre-hospital data on ventricular fibrillation/pulseless ventricular tachycardia until arrival at hospital, (iii) who experienced the return of spontaneous circulation after arriving at hospital. We compared the patients' prognosis after 1 and 3 months between various etiological and presumed cardiac factors. The proportion of the favorable brain function patients that developed pulmonary embolism or incidental hypothermia was significantly higher than that of the patients with presumed cardiac factors (1 month, P < 0.0001 and P < 0.0001, respectively; 3 months, P = 0.0018 and P < 0.0001, respectively). In multiple logistic regression analysis, pulmonary embolism and incidental hypothermia were found to be significant independent prognostic factors for 1- and 3-month survival and the favorable brain function rate. Conclusions: In patients who suffer non-shockable out-of-hospital cardiac arrest, but who experience the return of spontaneous circulation after arriving at hospital, the investigation and treatment of pulmonary embolism as a potential etiology may be important for improving post-resuscitation prognosis.

Feasibility study of immediate pharyngeal cooling initiation in cardiac arrest patients after arrival at the emergency room.

AIM: Cooling the pharynx and upper oesophagus would be more advantageous for rapid induction of therapeutic hypothermia since the carotid arteries run in their vicinity. The aim of this study was to determine the effects of pharyngeal cooling on brain temperature and the safety and feasibility for patients under resuscitation. METHODS: Witnessed non-traumatic cardiac arrest patients (n=108) were randomized to receive standard care with (n=53) or without pharyngeal cooling (n=55). In the emergency room, pharyngeal cooling was initiated before or shortly after return of spontaneous circulation by perfusing physiological saline (5 °C) into a pharyngeal cuff for 120 min. RESULTS: There was a significant decrease in tympanic temperature at 40 min after arrival (P=0.02) with a maximum difference between the groups at 120 min (32.9 ± 1.2°C, pharyngeal cooling group vs. 34.1 ± 1.3°C, control group; P<0.001). The return of spontaneous circulation (70% vs. 65%, P=0.63) and rearrest (38% vs. 47%, P=0.45) rates were not significantly different based on the initiation of pharyngeal cooling. No post-treatment mechanical or cold-related injury was observed on the pharyngeal epithelium by macroscopic observation. The thrombocytopaenia incidence was lower in the pharyngeal cooling group (P=0.001) during the 3-day period after arrival. The cumulative survival rate at 1 month was not significantly different between the two groups. CONCLUSIONS: Initiation of pharyngeal cooling before or immediately after the return of spontaneous circulation is safe and feasible. Pharyngeal cooling can rapidly decrease tympanic temperature without adverse effects on circulation or the pharyngeal epithelium.

[BLS in adults].

This manuscript expresses viewpoints on future pre-hospital care, mainly focusing on basic life support (BLS) by ambulance crew at emergency scenes, following recommendations of G2010. Ambulance workers need to have an ability to decide instantly "what you can do now to others" in every emergency scenes. Also it is necessary to always treat patients with the spirit of "generosity".

[How to cope with patients of drug dependency in emergent department].

In Japan, medical doctors are not obliged to accuse to the police, even if they diagnose a patient as intoxication of illegal drug. According to the queries to the doctors of the Tertiary Emergency Medical Center, variance of dealing existed. The promotion of the public health or interest and the duty to protect privileged information must be balanced. Each institution must prepare the manual for illegal drug patients. The limitations of qualitative analysis for drugs should be considered.

[Case of catecholamine-resistant shock caused by drug overdose].

A 27-year-old man with schizophrenia took an overdose of a psychotic agent. He became unconscious and had severe hypotension. Although he was diagnosed as having distributive shock caused by drug overdose and treated by hydration and catecholamine, the shock status was lasting. The use of vasopressin changed the situation dramatically. After the injection of vasopressin at maximum dose, 0.1 U/min, the dose of vasopressin could be tapered. He recovered from shock and was discharged on the third day without sequelae. There are an increasing number of reports that indicate that vasopressin is effective for distributive shock, especially catecholamine-resistant septic shock. It seems that the appropriate dose of vasopressin is under 0.04U/min considering the deterioration of cardiac function although the maximum dose of vasopressin was O.1U/min in this case. For that reason, monitoring by pulmonary artery catheter is recommended. The side effects of vasopressin should be discussed for appropriate use.