Effects of rewarming therapies on outcomes in accidental hypothermia: A secondary analysis of a multicenter prospective study.

BACKGROUND: Rewarming therapies for accidental hypothermia (AH) include extracorporeal membrane oxygenation (ECMO) and non-ECMO related (conventional) therapies. However, there are limited data available to inform the selection of conventional rewarming therapy. The aim of the present study was to explore what patients' factors and which rewarming therapy predicted favorable prognosis. METHODS: This study is a secondary analysis of the Intensive Care with Extra Corporeal membrane oxygenation Rewarming in Accidentally Severe Hypothermia (ICE-CRASH) study, a multicenter prospective, observational study conducted in Japan. Enrolled in the ICE-CRASH study were patients aged ≥18 years with a core temperature of ≤32 °C who were transported to the emergency departments of 36 tertiary care hospitals in Japan between 1 December 2019 and 31 March 2022, among whom those who were rewarmed with conventional rewarming therapy were included in the present study. Logistic regression analysis was performed with 28-day survival as the objective variable; and seven factors including age, activities of daily living (ADL) independence, sequential organ failure assessment (SOFA) score, and each rewarming technique as explanatory variables. We performed linear regression analysis to identify whether each rewarming technique was associated with rewarming rate. RESULTS: Of the 499 patients enrolled in the ICE-CRASH study, 371 were eligible for this secondary analysis. The median age was 81 years, 50.9% were male, and the median initial body temperature was 28.8 °C. Age (odds ratio [OR]: 0.97, 95% confidence interval [CI]: 0.94-1.00) and SOFA score (OR: 0.73, 95% CI: 0.67-0.81) were associated with lower survival, whereas ADL independence (OR: 2.31, 95% CI: 1.15-4.63) was associated with higher survival. No conventional rewarming therapy was associated with 28-day survival. Hot bath was associated with a high rewarming rate (regression coefficient: 1.14, 95% CI: 0.75-1.53). CONCLUSION: No conventional rewarming therapy was associated with improved 28-day survival, which suggests that background factors such as age, ADL, and severity of condition contribute more to prognosis than does the selection of rewarming technique.

Risk factors of pediatric ocular trauma related to ophthalmic complications.

BACKGROUND: Ocular injury is a leading cause of monocular blindness in children. However, data on the association of injury type with ophthalmological complications are lacking. This study aimed to investigate the risk factors of pediatric ocular injuries related to ophthalmological complications. METHODS: This retrospective, observational study was conducted in a pediatric emergency department (ED) in Japan from March 2010 to March 2021. Patients aged less than 16 years presenting with ocular trauma, diagnosed on the basis of the International Classification of Diseases 10: S05, 0-9, were enrolled. Emergency department follow-up visits for the same complaint were excluded. The patients' sex, age, arrival time, injury mechanism, symptoms, examinations, diagnosis, history of urgent ophthalmological consultation, outcomes, and ophthalmological complications were investigated. The primary endpoints were the odds ratio (OR) and 95% confidence interval (CI) of the incidence of ophthalmological complications, defined as any new acute complaint or worsening/persistence of an initial complaint following or resulting from ocular trauma. RESULTS: In total, 469 patients were analyzed. The median age was 7.3 years; the interquartile range (IQR) was 3.1-11.5 years. The most common diagnosis was contusion (79.3%), followed by lamellar laceration (11.7%). Seven patients (1.5%) had ophthalmological complications during follow up. Bivariate analysis demonstrated that daytime ED visit, impact with a sharp object, animal-related injury, visual impairment, decreased visual acuity, and open globe injury were factors significantly associated with ophthalmological complications. CONCLUSION: Daytime ED visit, impact with a sharp object, animal-related injury, visual impairment, decreased visual acuity, and open globe injury were independent factors of ophthalmological complications.

Association between residents' scholarly activities and publication requirement policy.

BACKGROUND: Scholarship is recognized as important in residency training worldwide. The Japan Pediatric Society (JPS) enacted a reform in 2017 to require publication of an article as a prerequisite for taking the board certification test, with the goal of increasing scholarly activity. METHODS: The purpose of this study was to provide a detailed description of the trends in residents' scholarly activities related to the JPS reform. A secondary analysis was performed on the cross-sectional database of pediatrics residents who took the certification test in 2015-2018. RESULTS: The enrolled participants were 2399 residents of which 79.7% passed the test. Publication of any type of article increased significantly (21%-22% to 100%; 0.1 to 0.3/person-year) after the implementation of the JPS reform, whereas academic presentations did not (89% to 91%; 1.2 to 1.3/person-year), both in terms of the percentage of the number of those who created them and the average rate of research production. Not only Japanese articles (11%-13% to 49%-53%; 0.04 to 0.15-0.17/person-year) or case reports (10%-14% to 51%-52%; 0.03-0.05 to 0.16-0.17/person-year), but also English articles (4%-5% to 15%-16%; 0.01-0.02 to 0.05/person-year) and original articles (5% to 11%-17%; 0.01 to 0.03-0.05/person-year) increased significantly. The number of each type of article publication was correlated with success in the board certification test (odds ratio 1.5-1.8). CONCLUSIONS: Scholarly activities of pediatrics residents were enhanced by the JPS implementation of the article requirement policy, which is crucial to fostering a scholarly culture. The most efficient measures to promote scholarship need to be persistently investigated.

Risk stratification of extravasation during semi-automatic intraosseous device use in a pediatric emergency setting.

BACKGROUND: The semi-automatic intraosseous device (EZ-IO®) is useful for safely securing intraosseous access. There are some complications associated with its use but few studies have examined the risk factors. The present study aimed to investigate the risk factors for extravasation as a complication of EZ-IO use in pediatric patients. METHODS: This study is a secondary analysis of a previous, monocentric, retrospective study conducted in Japan describing the use of EZ-IO in a pediatric emergency department. The patients included in the study were younger than 16 years of age with EZ-IO use at the Tokyo Metropolitan Children's Medical Center between January, 2013 and August, 2018. The factors analyzed included demographic information (sex, age, weight), Glasgow Coma Scale (GCS), diagnosis, bolus infusion, and lidocaine use. The primary endpoint was the odds ratio (OR) and 95% confidence interval (CI) for extravasation incidence. RESULTS: Seventy-two patients were enrolled; 14 of these had extravasation, 39 (54.2%) had a diagnosis of cardiac arrest, and 50 (69.4%) had a GCS score of 8 or less. Statistical analysis demonstrated that the group with a high GCS score was significantly associated with extravasation: GCS (<13) versus GCS (13≦) (OR: 12.25; 95% CI: 2.54-59.15; p < 0.01), GCS (<8) versus GCS (8≦) (OR: 4.78; 95% CI: 1.34-17.01; p = 0.03). CONCLUSIONS: A high GCS score was associated with extravasation in EZ-IO use significantly more often than a low GCS score. No significant difference was found in the other endpoints.

Effect of problem-based learning tutor seniority on medical students' emotions: an equivalence study.

BACKGROUND: The effectiveness of peer learning has been recognized and discussed by many scholars, and implemented in the formal curriculums of medical schools internationally. However, there is a general dearth of studies in measuring the objective outcomes in learning. METHODS: We investigated the objective effect of near-peer learning on tutee's emotions and its equivalence within the formal curriculum of a clinical reasoning Problem Based Learning session in a Japanese medical school. Fourth-year medical students were assigned to the group tutored by 6th-year students or by faculties. The positive activating emotion, positive deactivating emotion, negative activating emotion, negative deactivating emotion, Neutral emotion were measured using the Japanese version of the Medical Emotion Scale (J-MES), and self-efficacy scores were also assessed. We calculated the mean differences of these variables between the faculty and the peer tutor groups and were statistically analyzed the equivalence of these scores. The equivalence margin was defined as a score of 0.4 for J-MES and 10.0 for the self-efficacy score, respectively. RESULTS: Of the 143 eligible participant students, 90 were allocated to the peer tutor group and 53 were allocated to the faculty group. There was no significant difference between the groups. The 95% confidence interval of the mean score difference for positive activating emotions (-0.22 to 0.15), positive deactivating emotions (-0.35 to 0.18), negative activating emotions (-0.20 to 0.22), negative deactivating emotions (-0.20 to 0.23), and self-efficacy (-6.83 to 5.04) were withing the predetermined equivalence margins for emotion scores, meaning that equivalence was confirmed for these variables. CONCLUSIONS: Emotional outcomes were equivalent between near-peer PBL sessions and faculty-led sessions. This comparative measurement of the emotional outcomes in near-peer learning contributes to understanding PBL in the field of medical education.

'Caregivers' awareness matters': Call for a child-centred approach to early detection of autism spectrum disorder through well-child visits in Japan.

BACKGROUND: Early detection of autism spectrum disorder (ASD) is essential to provide children with timely treatment and support. Evidence-based screening measures make it possible to identify children with suspected ASD at an early stage. Although Japan has a universal healthcare system that covers well-child visits, detection rates of developmental disorders, including ASD, at 18 months vary widely between municipalities (0.2%-48.0%). The reasons for this high level of variation are poorly understood. The present study aims to describe the barriers and facilitators of incorporating ASD identification during well-child visits in Japan. METHODS: This is a qualitative study that conducts semi-structured in-depth interviews in two municipalities of Yamanashi Prefecture. We recruited all public health nurses (n = 17) and paediatricians (n = 11) involved in the well-child visit in each municipality and caregivers of children who also participated in the visits during the study period (n = 21). RESULTS: We identified four themes characterizing the process of ASD identification in the target municipalities: (1) Identification of children with ASD is driven by caregivers' sense of concern, acceptance and awareness. (2) Multidisciplinary cooperation and shared decision-making is limited. (3) Skills and training for developmental disabilities screening are underdeveloped. (4) Caregivers' expectations shape the interaction in important ways. CONCLUSIONS: Non-standardization of screening methods, limited knowledge and skills on screening and child development among healthcare providers and poor coordination among healthcare providers and caregivers are the main barriers to effective early detection of ASD through well-child visits. The findings suggest the importance of promoting a child-centred care approach through the application of evidence-based screening measures and effective information sharing.

Diagnostic accuracy of point-of-care ultrasound for paediatric testicular torsion: a systematic review and meta-analysis.

BACKGROUND: Previous studies have examined the utility of ultrasonography performed by radiologists for diagnosing paediatric testicular torsion. While point-of-care ultrasound (POCUS) is used in paediatric emergency medicine, its diagnostic accuracy is still unknown. OBJECTIVES: The present systematic review and meta-analysis aimed to clarify the accuracy of POCUS in diagnosing testicular torsion in children. METHODS: Following the Preferred Reporting Items for Systematic Review and Meta-analysis of Diagnostic Test Accuracy guidelines, a systematic review was performed using the indices of MEDLINE, EMBASE plus EMBASE classics, PubMed and the Cochrane database from inception to November 2020. Any study investigating the diagnostic accuracy of POCUS for paediatric testicular torsion was extracted. The primary outcome was the assessment of the diagnostic accuracy of POCUS for paediatric testicular torsion. The pooled sensitivity and specificity were calculated. Quality analysis was conducted using Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2). RESULTS: Four studies enrolling 784 patients in total were included. The pooled sensitivity, specificity, and positive and negative likelihood ratios of POCUS were 98.4% (95% CI: 88.5% to 99.8%), 97.2% (95% CI: 87.2% to 99.4%), 34.7 (95% CI: 7.4 to 164.4) and 0.017 (95% CI: 0.002 to 0.12), respectively. Risk-of-bias assessment using QUADAS-2 revealed that two of the studies had a high risk of bias in patient selection. CONCLUSION: The present systematic review and meta-analysis showed that POCUS had high sensitivity and specificity for identifying testicular torsion in paediatric patients although the risk of bias was high in the studies analysed.

Enterolith Treated with a Combination of Double-Balloon Endoscopy and Cola Dissolution Therapy.

A 71-year-old woman with rheumatoid arthritis who had been taking NSAIDs for many years consulted our hospital for abdominal pain. She was diagnosed with a small bowel obstruction due to an enterolith according to an abdominal CT scan that showed dilation from the enterolith in the small intestine on the oral side. It was considered that the intestinal stone was formed due to stagnation of intestinal contents and had gradually increased in size, resulting in an intestinal obstruction. We performed antegrade double-balloon endoscopy (DBE) to observe and remove the enterolith. We used forceps and a snare to fracture the enterolith. During this attempt, we found a seed in the center of the enterolith. Since the intestinal stone was very hard, cola dissolution therapy was administered from an ileus tube for 1 week. The following week, DBE was performed again, and it was found that the stone had further softened, making attempts at fracture easier. Finally, the enterolith was almost completely fractured. Intestinal stenosis, probably due to ulcers caused by NSAIDs, was found. Small bowel obstruction with an enterolith is rare. In this case, it was considered that the seed could not pass through the stenotic region of the small intestine and the intestinal contents had gradually built up around it. It has been suggested that DBE may be a therapeutic option in cases of an enterolith. Further, cola dissolution therapy has been shown to be useful in treating an enterolith, with the possible explanation that cola undergoes an acid-base reaction with the enterolith. In summary, we report, for the first time, treatment of an enterolith with a combination of DBE and cola dissolution therapy, thereby avoiding surgery and its risks.

Early Initiation of Venovenous Extracorporeal Membrane Oxygenation for Critically Ill COVID-19 Patients.

The optimal timing for initiating extracorporeal membrane oxygenation (ECMO) after starting mechanical ventilation has yet to be clarified. We report herein the cases of two patients with coronavirus disease 2019 (COVID-19) acute respiratory distress syndrome (ARDS) who were successfully managed with an early ECMO induction strategy. Case 1 involved a 64-year-old man admitted in respiratory distress with polymerase chain reaction-confirmed COVID-19. On day 5 at hospital, he was intubated, but oxygenation remained unimproved despite mechanical ventilation treatment with high positive end-expiratory pressure (PEEP) (PaO2/FiO2 [P/F] ratio, 127; Respiratory ECMO Survival Prediction [RESP] score, 4). ECMO was initiated 4 hours after intubation, and stopped on day 16 at hospital. The patient was discharged from hospital on day 36. Case 2 involved a 49-year-old man who had been admitted 8 days prior. He was intubated on hospital on day 2. High PEEP mechanical ventilation did not improve oxygenation (P/F ratio, 93; RESP score, 7). ECMO was stopped on hospital on day 7 and he was discharged from hospital on day 21. The strategy of early initiation of ECMO in these two cases may have minimized the risk of ventilation-related lung injury and contributed to the achievement of favorable outcomes.

A Comparative Study of Early Mucosal Healing Following Hot Polypectomy and Cold Polypectomy.

BACKGROUND Cold polypectomy (CP) and hot polypectomy (HP) are both accepted methods for polypectomy. In recent years, the use of CP has increased for reasons of safety. However, there have been few investigations of conditions at follow-up early after resection. This prospective study from a single center aimed to compare colonic mucosal healing at 1 week following HP vs CP of benign colonic polyps <10 mm in diameter. MATERIAL AND METHODS Six patients with a total of 52 lesions under 10 mm in size were randomized to either the HP group (n=25) or CP group (n=27) using information in opaque envelopes. One week after endoscopic treatment, the site of treatment was evaluated using colonoscopy. We assessed the mean tumor size, ulcer diameter, exposed blood vessels, residual lesion, and complications. RESULTS Mean tumor size did not differ between the 2 groups (CP vs HP: 5.41 mm vs 5.68 mm). The CP group had a smaller ulcer base diameter (2.70 mm vs 4.84 mm; P<0.05) and fewer exposed blood vessels than the HP group (3.7% vs 36.0%; P<0.05). One residual lesion was found in the CP group. No patients experienced delayed perforation or post-polypectomy bleeding. CONCLUSIONS Our study findings showed that at 1-week follow-up, cold polypectomy resulted in improved colonic mucosal healing, with a smaller ulcer diameter and fewer blood vessels, when compared with hot polypectomy.

Japanese medical learners' achievement emotions: Accounting for culture in translating Western medical educational theories and instruments into an asian context.

Medical learners' achievement emotions during educational activities have remained unexamined in Asian cultural contexts. The Medical Emotion Scale (MES) was previously developed to assess achievement emotions experienced by North American medical learners during learning activities. The goal of this study was to create and validate a Japanese version of the Medical Emotion Scale (J-MES). We translated the MES into Japanese and conducted two initial validation studies of the J-MES. In the first pilot study, we asked five, native-Japanese, second-year medical students to assess their emotions with the J-MES during a computer-based clinical reasoning activity. Each participant was then interviewed to assess the clarity and suitability of the items. In a second, larger study, 41 Japanese medical students were recruited to assess the psychometric properties of the J-MES. We also conducted individual, semi-structured interviews with ten of these participants to explore potential cultural features in the achievement emotions of Japanese students. The first pilot study demonstrated that the J-MES descriptions were clear, and that the scale captured an appropriate range of emotions. The second study revealed that the J-MES scale's profiles and internal structure were largely consistent with control-value theory. The achievement emotions of pride, compassion, and surprise in the J-MES were found to be susceptible to cultural differences between North American and Japanese contexts. Our findings clearly demonstrated the scoring capacity, generalizability, and extrapolability of the J-MES.

Predictors of performance on the pediatric board certification examination.

BACKGROUND: Examining the predictors of summative assessment performance is important for improving educational programs and structuring appropriate learning environments for trainees. However, predictors of certification examination performance in pediatric postgraduate education have not been comprehensively investigated in Japan. METHODS: The Pediatric Board Examination database in Japan, which includes 1578 postgraduate trainees from 2015 to 2016, was analyzed. The examinations included multiple-choice questions (MCQs), case summary reports, and an interview, and the predictors for each of these components were investigated by multiple regression analysis. RESULTS: The number of examination attempts and the training duration were significant negative predictors of the scores for the MCQ, case summary, and interview. Employment at a community hospital or private university hospital were negative predictors of the MCQ and case summary score, respectively. Female sex and the number of academic presentations positively predicted the case summary and interview scores. The number of research publications was a positive predictor of the MCQ score, and employment at a community hospital was a positive predictor of the case summary score. CONCLUSION: This study found that delayed and repeated examination taking were negative predictors, while the scholarly activity of trainees was a positive predictor, of pediatric board certification examination performance.

Detection of a Urethral Foreign Body in a Pediatric Patient: Another Useful Application of Point-of-Care Ultrasound.

BACKGROUND: Urethral foreign bodies (UFBs) are rare in pediatric emergency care, but require immediate diagnosis and intervention when they occur. Although radiography, computed tomography, and cystography are available for diagnosing UFBs, these modalities are undesirable because they involve radiation exposure. Point-of-care ultrasound (POCUS) is used as an alternative imaging modality for UFB detection in adult patients, but reports of its use in pediatric emergency departments are still scarce. We report a pediatric case of a UFB detected by POCUS. CASE REPORT: A 10-year-old boy with a history of a learning disorder presented to our pediatric emergency department with a paper clip in his penis, which he had intentionally inserted during play. He denied any symptoms, such as abdominal pain, vomiting, and hematuria. Physical examination failed to reveal the tip of the FB, but showed a palpable mass in the penile urethra accompanied by mild tenderness in the area. POCUS demonstrated a hyperechoic structure with reverberation artifact extending to the bulbar urethra. Endoscopic removal was planned, but the tip of the FB emerged from the external urethral meatus with postural change. Manual removal was successfully performed, after which the hyperechoic structure in the urethra was no longer visible on ultrasonography. The patient was discharged on the same day of the procedure. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: POCUS is a noninvasive procedure that can be useful for detecting UFBs in children.

Endoscopic ultrasound-guided antegrade procedures for managing bile duct stones in patients with surgically altered anatomy: Comparison with double-balloon enteroscopy-assisted endoscopic retrograde cholangiography (with video).

BACKGROUND AND STUDY AIM: Management of bile duct stones (BDSs) in patients with surgically altered anatomies (SAAs) remains challenging. An endoscopic ultrasound-guided antegrade (EUS-AG) procedure and double-balloon enteroscopy-assisted endoscopic retrograde cholangiography (DB-ERC) have been used to remove BDSs from patients with SAAs. However, few comparative data have been reported. Therefore, we compared the efficacy and safety of the techniques. METHODS: This was a single-center retrospective study. Patients with SAA who underwent the EUS-AG procedure or DB-ERC to remove intra- or extra-BDSs between November 2010 and March 2020 were included. The primary outcome was the technical success rate, defined as stent insertion or stone removal during the initial session. The secondary outcomes were the procedure time, incidence of adverse events (AEs), and complete stone removal rate. RESULTS: Of the 54 patients enrolled, 23 underwent the EUS-AG procedure and 31 DB-ERC. The technical success rates of EUS-AG and DB-ERC were 87.0% and 64.5%, respectively (P = 0.11). The procedure time was significantly shorter in the EUS-AG group than in the DB-ERC group (51.9 ± 15.4 vs 72.6 ± 32.2 min; P = 0.01), and the early AE rates were 26.1% and 12.9%, respectively (P = 0.71). The complete stone removal rates in patients who underwent previous stone removal were 94.1% in the EUS-AG group and 85.7% in the DB-ERC group (P = 0.61). CONCLUSION: The EUS-AG afforded technical success and complete stone removal rates comparable with those of DB-ERC, but the former procedure was shorter. The AE rate was acceptable.

The Management of Pediatric Genital Injuries at a Pediatric Emergency Department in Japan.

OBJECTIVES: Genital injuries among children are often associated with consumer products or specific activities. There are few descriptive studies from Asia on pediatric genital injuries seen in the emergency department (ED). The aim of this study was to describe the characteristic features of accidental genital injuries among children. METHODS: A retrospective chart review of children aged 15 years or younger who visited our ED for genital injuries between March 2010 and November 2014 was conducted. Data on age, arrival time at the ED, location of the incident, mechanism of injury, objects, injured organ, consultation with specialists, emergency operation, sedation at the ED, and outcomes were collected and analyzed. RESULTS: One hundred seventy-nine patients were included in this analysis. Girls comprised 71% of the subject pool. The median age was 6 years (interquartile range, 4-9 years). Straddle injuries were the most common form of injury (56%). Male genital injuries occurred mostly outdoors (64%). Common consumer products associated with pediatric genital injuries were furniture (21%), exercise equipment (17%), and bicycles (15%). Thirty-two patients were examined by a surgeon, gynecologist, or urologist. The most commonly injured organs were the penis (55%) in boys and the labia (60%) in girls. Most patients (93%) were treated at the ED and discharged. CONCLUSIONS: The characteristics of accidental genital injuries among Japanese children were similar to those of children in other countries. The strategy for preventing genital injuries used in the West might be applicable to the East Asian context.

Ultrasound-guided nasogastric tube placement in a pediatric emergency department.

Nasogastric tube (NGT) insertion is commonly performed in pediatric emergency care. Point-of-care ultrasound is used for confirming NGT insertion, but reports of its use in the pediatric emergency department (ED) are scarce. We describe our experience of ultrasound-guided NGT placement in a pediatric ED. The study pool consisted of twelve patients and the NGT tip was successfully visualized in the esophagus and gastric cardia in all cases, demonstrating that ultrasound has the potential to be a useful alternative to conventional methods of NGT insertion in the pediatric ED.

Effectiveness of Cytapheresis for Ulcerative Colitis in Special Situations: Delayed Onset of Optimum Efficacy in Elderly Patients.

BACKGROUND: Cytapheresis is a non-pharmacologic treatment option in which depleting elevated/activated leucocytes is known to exacerbate and perpetuate ulcerative colitis (UC) by releasing inflammatory cytokines. Therefore, it is a relevant treatment for elderly patients who wish to avoid pharmacologicals. METHODS: The efficacy of Cytapheresis for remission induction in 72 patients who received Cytapheresis for active UC at our hospital was retrospectively evaluated. Patients included 11 elderly cases, patients on steroids, biologics, calcineurin inhibitor, and 13 with extra-intestinal complications. Lichtiger's UC clinical activity index ≤4 meant remission was assessed at the end of therapy and then 1 month later. The efficacy on extra-intestinal manifestations meant improvement of the main morbidity. RESULTS: At the end of Cytapheresis therapy, the remission rate in the elderly was 36.4%, and 54.2% in the non-elderly patients. One-month post Cytapheresis, the remission rate in the elderly had increased to 72.7% (p = 0.042), but to 58.3% in the non-elderly, suggesting a delayed response phenomenon in the elderly. The efficacy of Cytapheresis in 4 cases with loss of response to biologics was 75%, and 84.6% in the 13 patients with extra-intestinal complications, indicating a dramatic efficacy on dermatitis and arthralgia. CONCLUSIONS: Unlike pharmacologicals, the efficacy of Cytapheresis appears to be time dependent. Accordingly, in the elderly, we observed a delayed response, indicating that elderly patients may respond beyond the end of Cytapheresis therapy. Therefore, patients who do not show efficacy at the end of Cytapheresis therapy should be followed up for delayed response. Further, Cytapheresis is favored by patients for its good safety profile.

Pyoderma gangrenosum in an ulcerative colitis patient during treatment with vedolizumab responded favorably to adsorptive granulocyte and monocyte apheresis.

Pyoderma gangrenosum (PG) is an extra-intestinal skin lesion in inflammatory bowel disease (IBD) as is erythema nodosum. Vedolizumab (VED) is a monoclonal antibody that targets α4ß7 integrin and has an intestinal selective mechanism. Despite good therapeutic effects on colitis, the effect on extra-intestinal manifestations (EIMs) remains unclear. Here we report a case of ulcerative colitis complicated by PG during treatment with VED, which was successfully treated with prednisolone in combination with adsorptive granulocyte and monocyte apheresis (GMA). The patient was a 50-year-old woman with a past medical history of extensive ulcerative colitis managed by golimumab (GLM). She developed flare symptoms due to loss of response to GLM, and treatment was switched to VED. Her gastrointestinal symptoms were improved with VED treatment with less frequent bowel movements. However, infiltrative erythema with pain appeared on the right lower leg and right knee, and expanded and gradually ulcerated. Her skin lesions were treated with corticosteroid, but showed poor improvement. Therefore, granulocyte and monocyte apheresis (GMA) treatment was administered in combination with prednisolone. After 3 months, the ulcer gradually improved, and at the time of this writing, the eruptions were nearly replaced by epithelial tissue. This case study showed that patients with UC and EIMS may respond well to combination therapy of VED and GMA. GMA has a very favorable safety profile. On the other hand, the causal connection between VED and PG is still unclear. We believe that a combination therapy involving VED and GMA in IBD patients with EIMs warrants consideration.

Semi-automatic intraosseous device (EZ-IO) in a paediatric emergency department.

AIM: Intraosseous access is an alternative to conventional intravenous access. A number of studies have demonstrated the utility and safety of EZ-IO, a recently introduced semi-automatic intraosseous device. However, few studies have investigated the use of EZ-IO in the paediatric emergency setting. The aim of this study was to describe the epidemiological characteristics EZ-IO use including complications among paediatric patients in a paediatric emergency department. METHODS: We conducted a retrospective descriptive study enrolling children younger than 16 years who visited our emergency department between January 2013 and August 2018. Data on age, gender, diagnosis, insertion success rate and complications were collected and analysed. RESULTS: Seventy-two patients were enrolled; of these 38 (52.8%) were male. The median age was 9 months (interquartile range: 3-34.5 months). Of the total, 22 (30.6%) received more than one IO insertion. Ninety-seven consecutive IO insertions were identified. The rate of successful insertions was achieved at 92.7% (90 insertions). There were 21 complications (21.6%), including 17 extravasations (17.5%) of fluid and four dermal abrasions (4.1%). We found no cases of complications that may have compromised patient safety. CONCLUSIONS: The success rate of the EZ-IO insertion was high in paediatric patients. However, we found a higher incidence of dermal abrasions, which might be a complication specific to children.

Incidence and aetiology of serious viral infections in young febrile infants.

AIM: While the incidence and aetiology of serious bacterial infections among febrile infants younger than 90 days old are well studied, those concerning viral infection are not. There are severe life-threatening viral infections requiring immediate intense therapy. The objective of the study is to describe the incidence and aetiology of serious viral infections (SVI) among young febrile infants. METHODS: A retrospective audit was performed covering all the febrile infants younger than 90 days old admitted to a paediatric emergency department in Japan from 2011 to 2013. SVI was defined as a viral illness that may result in permanent organ dysfunctions or life-threatening complications. Diagnostic investigation consisted of urine and blood culture for all infants, cerebrospinal fluid cultures for infants who do not fulfil the low-risk criteria, rapid antigen tests for several viruses in infants with specific symptoms and blood and/or cerebrospinal fluid polymerase chain reaction of possible viruses for infants with fever without a localising source. RESULTS: Of 275 cases, 32 and 45 cases were diagnosed as serious viral and bacterial infections, respectively. Intensive care unit admission occurred for three viral and four bacterial infections. Viral aetiology consisted of respiratory syncytial virus (11 cases), aseptic meningitis (9 cases), enterovirus (6 cases), influenza virus (3 cases), rotavirus (2 cases) and herpes simplex virus-1 (1 case). Respiratory (14 cases), central nervous (12 cases) and circulatory (6 cases) systems were affected. CONCLUSION: SVI was observed in 11.6% of febrile young infants in a paediatric emergency department.