Bladder deformity accompanied by pelvic fracture indirectly indicates clinical severity.

BACKGROUND: That the bladder can be compressed by extraperitoneal hematoma induced by obstetrics and gynecologic diseases, is well known. However, there have been no reports on the clinical significance of compressed bladder induced by pelvic fracture (PF). We therefore retrospectively investigated the clinical features of compressed bladder induced by the PF. METHODS: From January 2018 to December 2021, we performed a retrospective review of the hospital medical charts of all emergency outpatients who were treated by emergency physicians at the department of acute critical care medicine in our hospital, and who were diagnosed with PF based on computed tomography (CT) on arrival. The subjects were divided into two groups: the Deformity group, in which the bladder was compressed by extraperitoneal hematoma, and the Normal group. Variables were compared between the two groups. RESULTS: During the investigation period, 147 patients with PF were enrolled as subjects. There were 44 patients in the Deformity group and 103 in the Normal group. There were no significant differences between the two groups with regard to sex, age, GCS, heart rate or final outcome. However, the average systolic blood pressure in the Deformity group was significantly lower, and the average respiratory rate, injury severity score, rate of unstable circulation, rate of transfusion and duration of hospitalization in the Deformity group were significantly greater in comparison to the Normal group. CONCLUSIONS: The present study showed that bladder deformity induced by PF tended to be a poor physiological sign that was associated with severe anatomical abnormality, unstable circulation requiring transfusion, and long hospitalization. Accordingly, physicians should evaluate shape of bladder when treating PF.

Usefulness of Key Word Methods to Execute Early Requests for a Physician-Staffed Helicopter Emergency Medical Service Dispatch to Facilitate Early Medical Intervention by Physicians.

OBJECTIVE: A physician-staffed helicopter emergency medical service is called a doctor helicopter (DH) in Japan. We retrospectively investigated this service using a data bank provided by the Japan DH registry system. METHODS: The following details of the dispatch activity were collected: patient age and sex, vital signs (Japan Coma Scale [JCS], systolic blood pressure, heart rate, and respiratory rate) at the scene measured by emergency medical technicians (EMTs), dispatch of the DH before the EMTs made contact with patients (key words group) or after (control group), and the survival outcome at 1 month. RESULTS: During the investigation period, 28,357 patient records were analyzed (key words group, n = 13,861; control group, n = 14,496). The age, JCS, and respiratory rate were significantly smaller in the key words group than in the control group. The rates of male sex and survival in the key words group were significantly greater than those in the control group. In the multivariate analysis, dispatch of the DH after EMTs made contact with the patients (odds ratio [OR] = 0.72; 95% confidence interval [CI], 0.55-0.92), female sex (OR = 0.86; 95% CI, 0.75-0.98), older age (OR = 0.97; 95% CI, 0.96-0.97), elevated respiratory rate (OR = 0.97; 95% CI, 0.97-0.98), and high JCS (OR = 0.99; 95% CI, 0.99-0.99) were associated with a decreased 1-month survival (P > .0001). CONCLUSION: This is the first report to describe the key words method as a potential factor influencing optimal outcomes/potential survival rates in patients evacuated by the DH using the JDRS. Our study results suggest that the firefighting central command room should consider adopting the key words method when the helicopter emergency medical service is used.

A Comparison of Tube Thoracostomy for Chest Trauma Between Prehospital and Inhospital Settings.

OBJECTIVE: We compared the outcomes of patients with tube thoracostomy for chest trauma between the prehospital and inhospital settings. METHODS: The subjects were then divided into 2 groups: the prehospital group, which included subjects who underwent tube thoracostomy in the prehospital setting, and the inhospital group, which included subjects who underwent tube thoracostomy in the inhospital setting. The variables were compared between the 2 groups. RESULTS: There were no significant differences between the 2 groups with regard to gender, age, history, mechanism of injury, infusion of antibiotics, white blood cell count, duration of insertion of a chest drain, mechanical ventilation, complication of drain infection, duration of admission, or final outcome. However, the Injury Severity Score, maximum C-reactive protein level, and maximum temperature during hospitalization in the prehospital group (n = 15) were significantly greater than those in the inhospital group (n = 119). CONCLUSION: The present study suggested that thoracostomy performed by physicians in the prehospital setting was safe and did not have an increased risk of infection. In addition, thoracostomy for chest injury in the prehospital setting suggested an improvement in the likelihood of a survival outcome.

Patients With Atrioventricular Block Transported by a Physician-Staffed Helicopter in Japan From 2015 to 2020.

OBJECTIVE: We retrospectively investigated the current status of patients with atrioventricular block (AVB) who had been transported by the physician-staffed helicopter emergency medical service and their final outcome using data from the Japan Doctor Helicopter Registry (JDHR) system. METHODS: The following details of the dispatch activity were collected from the database of the JDHR: age and sex, vital signs when emergency medical technicians encountered the patient at the scene and on arrival at the receiving hospitals, contents of the medical intervention, new cardiac arrest during transportation, the main etiology of AVB, and the number of deaths in 1 month. The changes in vital signs between the scene and upon arrival at the hospital were compared. RESULTS: A total of 99 patients had complete AVB. The average age of the patients was 75 years, and there was a male predominance. All subjects were evacuated from the scene. Among the 62 subjects who received the drugs, 18 received atropine. Six patients underwent percutaneous pacing. None of the patients developed a new cardiac arrest during transportation. The average Glasgow Coma Scale score and heart rate upon arrival at the hospital were significantly greater than those at the scene. CONCLUSION: The present study showed the current status of patients with AVB who were transported by a doctor helicopter using registry data from the JDHR. The present findings suggest that a doctor helicopter could provide safe transportation for patients with AVB.

Analysis of the Activities of a Physician-Staffed Helicopter in the Coronavirus Disease 2019 Pandemic Phase.

OBJECTIVE: The purpose of this study was to investigate changes in the duration of activity of a physician-staffed helicopter emergency medical service (HEMS) in Eastern Shizuoka Prefecture before and during the coronavirus disease 2019 pandemic. METHODS: We retrospectively investigated the duration of dispatch activities from February 2020 to June 2021 (pandemic group, n = 1,032) and from April 2016 to January 2020 (control group, n = 3,054). RESULTS: There were no significant differences in the average age, percentage of male patients, interval from the request of HEMS dispatch to arrival, interval from arrival at the scene to leaving the scene, interval from leaving the scene to arrival at the hospital, or the ratio of requests for HEMS dispatch from the local fire department between the control and pandemic groups. In contrast, the interval from the first call to HEMS dispatch in the control group was significantly shorter than that in the pandemic group, and the ratio of requests for HEMS dispatch before contacting patients in the control group was significantly greater than that in the pandemic group. CONCLUSION: The interval from the first call to HEMS dispatch was prolonged in the COVID-19 pandemic period. However, the actual activity time of the HEMS was not affected.

An analysis of patients with acute aortic dissection who were transported by physician-staffed helicopter.

PURPOSE: The present study aimed to determine whether or not patients with acute aortic dissection (AAD) treated by the staff of a doctor helicopter (DH) service while being transported from the scene or for interhospital transportation obtained a favorable outcome. METHODS: We retrospectively investigated all patients with AAD who were transported by DH between January 2015 and December 2019 using the registry data of the DH control room of our hospital. RESULTS: One hundred five cases were enrolled in the present study. All patients were transported within 24 h from the onset. Male patients accounted for 55.2% of the study population, the average age was 71 years and the rate of Stanford A AAD was 51.4%. Regarding transportation, 61.6% of the patients underwent interhospital transportation, and 42.8% were transported to our hospital. All patients underwent drip infusion during transportation and 81.9% of the patients received drugs (e.g., depressors, pain killers and/or antiemetics). Two patients underwent tracheal intubation due to unconsciousness and profound shock with restless state, respectively. The systolic blood pressure after transportation to hospital was significantly higher in comparison to before transportation. No patients suffered cardiac arrest or showed a deterioration of vital signs. All patients were safely transported to the destination. CONCLUSION: The present study suggests the safety of using a Dr. Heli to transport AAD patients from the scene and for interhospital transportation, even after the onset.

Significance of medical intervention for non-traumatic hemorrhagic cardiac tamponade.

BACKGROUND: The outcomes of patients with cardiac arrest induced by non-traumatic hemorrhagic cardiac tamponade are poor. PURPOSE: We retrospectively investigated the significance of medical intervention with pericardiocentesis and/or pericardiotomy for non-traumatic hemorrhagic cardiac tamponade. METHODS: From January 2013 to April 2021, we retrospectively reviewed the medical charts of all patients with cardiac arrest in a prehospital setting or emergency room due to cardiac tamponade confirmed by an ultrasound examination with or without an invasive procedure (pericardiocentesis and/or pericardiotomy) and computed tomography findings, including those obtained at autopsy imaging. The subjects were divided into two groups: the Intervention (+) group, which included subjects who underwent pericardiocentesis or pericardiotomy, and the Intervention (-) group, which included subjects who did not undergo pericardiocentesis or pericardiotomy. Variables were then compared between the two groups. RESULTS: There were 68 patients with non-traumatic cardiac tamponade. All three survival cases had witnessed collapse, and the initial rhythm was pulseless electrical activity (PEA).There were no statistically significant differences in the sex, age, means of transportation, bystander chest compression, electric shock, or adrenalineor FDP levels between the two groups.However, the number with witnessed collapse, PEA, rupture of the heart;the ratio of obtaining return of spontaneous circulation; and the survival ratio were significantly greater in the Intervention (+) group than in the Intervention (-) group. CONCLUSION: Based on the results of preliminary study, we hypothesized that invasive medical intervention for patients with cardiac arrest induced by non-traumatic hemorrhagic cardiac tamponade might be useful for obtaining return of spontaneous circulation and a survival outcome, especially for patients with witnessed collapse with PEA as the initial rhythm.

A comparison of physician-staffed helicopters and ground ambulances transport for the outcome of severe thoracic trauma patients.

PURPOSE: We retrospectively investigated prognostic factors for severe thoracic trauma patients evacuated by a physician-staffed helicopter emergency medical service (HEMS) and ground ambulance using the Japan Trauma Data Bank (JTDB). METHODS: This study was a retrospective analysis of the JTDB database. The study period was from January 2004 to May 2019. The subjects were divided into two groups, according to the type of transportation: the Heli group included cases transported by the HEMS, while the Ambulance group included cases transported by ground ambulance. RESULTS: During the investigation period, a total of 57,872 patients were enrolled as subjects, including 7238 in the Heli group and 50,634 in the Ambulance group. The average age, male ratio, average injury severity score (ISS), average revised trauma score (RTS) and survival ratio were significantly greater in the Heli group than in the Ambulance group. After performing a propensity score-matched analysis, there were no statistical differences concerning the age, sex, ISS, RTS between the two groups. However, the survival ratio in the Heli group remained greater than that in the Ambulance group. When variables that showed statistical significance in the univariate analysis were included in a multivariate analysis, the RTS, transport by the HEMS, age, ISS and female gender were identified as significant predictors of a survival outcome. The HEMS was significantly associated with an increased survival ratio (odds ratio: 1.69; 95% confidence interval: 1.51-1.88) compared with a ground ambulance. CONCLUSION: The present study showed that transport by the HEMS improved the survival rate compared to that by a ground ambulance for patients with severe thoracic trauma.

High-Fat Diet and Age-Dependent Effects of IgA-Bearing Cell Populations in the Small Intestinal Lamina Propria in Mice.

Several studies highlighted that obesity and diabetes reduce immune function. However, changes in the distribution of immunoglobins (Igs), including immunoglobulin-A (IgA), that have an important function in mucosal immunity in the intestinal tract, are unclear. This study aimed to investigate the impaired immune functions in the context of a diet-induced obese murine model via the assessment of the Igs in the intestinal villi. We used mice fed a high-fat diet (HFD) from four to 12 or 20 weeks of age. The distributions of IgA, IgM, and IgG1 were observed by immunohistochemistry. Interestingly, we observed that IgA was immunolocalized in many cells of the lamina propria and that immunopositive cells increased in mice aged 12 to 20 weeks. Notably, mice fed HFD showed a reduced number of IgA-immunopositive cells in the intestinal villi compared to those fed standard chow. Of note, the levels of IgM and IgG1 were also reduced in HFD fed mice. These results provide insights into the impaired mucosal immune function arising from diet-induced obesity and type 2 diabetes.

Functional and Structural Changes in the Corticospinal Tract of Streptozotocin-Induced Diabetic Rats.

This study aimed to reveal functional and morphological changes in the corticospinal tract, a pathway shown to be susceptible to diabetes. Type 1 diabetes was induced in 13-week-old male Wistar rats administered streptozotocin. Twenty-three weeks after streptozotocin injection, diabetic animals and age-matched control animals were used to demonstrate the conduction velocity of the corticospinal tract. Other animals were used for morphometric analyses of the base of the dorsal funiculus of the corticospinal tract in the spinal cord using both optical and electron microscopy. The conduction velocity of the corticospinal tract decreased in the lumbar spinal cord in the diabetic animal, although it did not decrease in the cervical spinal cord. Furthermore, atrophy of the fibers of the base of the dorsal funiculus was observed along their entire length, with an increase in the g-ratio in the lumbar spinal cord in the diabetic animal. This study indicates that the corticospinal tract fibers projecting to the lumbar spinal cord experience a decrease in conduction velocity at the lumbar spinal cord of these axons in diabetic animals, likely caused by a combination of axonal atrophy and an increased g-ratio due to thinning of the myelin sheath.

Experience Using a Forehead Continuous Deep Temperature Monitoring System During Air Evacuation.

OBJECTIVE: The present study describes the utility of a forehead continuous deep temperature monitoring system by the staff members of a doctor helicopter (DH). METHODS: A questionnaire survey was performed for all flight doctors who had used this system during transportation by the DH to assess its merits and demerits. RESULTS: The major benefits of this system were its easy usability, disposable nature, low labor cost, continuous demonstration of the deep temperature in a prehospital setting, and low invasiveness. However, drawbacks of this system include its cost; need for a power supply; need for a few minutes for calibration to obtain stable results of temperature, making it impossible to verify the effects of intervention for body temperature during a short flight; and lack of a detachable measuring pad for the forehead when a patient has an injury on the face or head and hyperhidrosis. In addition, the system's attached cables may hamper medical interventions. CONCLUSION: We reported the experience of DH staff using a forehead continuous deep temperature monitoring system in the prehospital setting. Further studies will be required to determine the indications for using such a system in the prehospital setting.

Pain thresholds are unaffected by age in a Japanese population.

INTRODUCTION: Assessment of sensory impairment in diabetic patients by pain threshold test using intraepidermal electrical stimulation (IES) is a recently developed technique. However, there are no normative pain thresholds in healthy people. METHODS: We examined pain, vibration, and pressure thresholds in 178 healthy subjects using IES, vibration perception testing (VPT), and Semmes-Weinstein monofilament testing (SWMT). RESULTS: The mean values for each age group for pain threshold ranged from 0.07 to 0.12 mA. Pain thresholds were unaffected by age. As the age increased, VPT values decreased from 18.0 to 10.6 seconds and SWMT values increased from 21.4 to 45.3 g/mm2 . There were no significant differences in pain threshold, VPT, and SWMT between men and women. DISCUSSION: The pain threshold test appears to be useful for diabetic neuropathy screening because normative values are not affected by age.

A case of iliopsoas hematoma as a complication of tetanus in a patient who did not receive anticoagulant therapy.

BACKGROUND: The specific clinical feature of tetanus is whole body muscle spasms. These spasms are intensely painful and sometime lead to some injuries. Vertebral fractures have been reported as a common complication of tetanus, however iliopsoas hematoma is a rare complication. We describe a case of iliopsoas hematoma in a tetanus patient who had not been treated with any anticoagulant or antiplatelet agents. CASE PRESENTATION: A 72-year-old female patient was transferred to our hospital 7 days after the onset of tetanus. An iliopsoas hematoma was identified in her right iliopsoas muscle on computed tomography. There was no extravasation; thus, the hematoma improved with conservative therapy. There were no episodes that suggested a bleeding tendency, or no factors associated with hemorrhagic conditions. CONCLUSION: This is the first report of iliopsoas hematoma as a complication in a tetanus patient who did not received anticoagulation therapy. The possibility of IPH as a complication of tetanus should be considered before and during the administration of anticoagulation therapy.

Non-tuberculosis cold abscess.

An 85-year-old cachectic man was found unconscious in his home. He had no specific medical history. On arrival, he was in a deep coma and hypothermic state. He had a soft mass the size of his fist in the right lower abdomen without redness or heat. Truncal computed tomography revealed subcutaneous fluid collection with gas formation. A test puncture for right lower abdominal subcutaneous fluid collection revealed pus, so an open incision was performed, with the administration of broad-spectrum antibiotics. Unfortunately, the patient died of sepsis-induced multiple organ failure. The results of abscess culture later revealed Proteus mirabilis, Escherichia coli, and Prevotella melaninogenica. This is the first report of a cold abscess induced by mixed bacteria.

Diabetes Mellitus-Related Dysfunction of the Motor System.

Although motor deficits in humans with diabetic neuropathy have been extensively researched, its effect on the motor system is thought to be lesser than that on the sensory system. Therefore, motor deficits are considered to be only due to sensory and muscle impairment. However, recent clinical and experimental studies have revealed that the brain and spinal cord, which are involved in the motor control of voluntary movement, are also affected by diabetes. This review focuses on the most important systems for voluntary motor control, mainly the cortico-muscular pathways, such as corticospinal tract and spinal motor neuron abnormalities. Specifically, axonal damage characterized by the proximodistal phenotype occurs in the corticospinal tract and motor neurons with long axons, and the transmission of motor commands from the brain to the muscles is impaired. These findings provide a new perspective to explain motor deficits in humans with diabetes. Finally, pharmacological and non-pharmacological treatment strategies for these disorders are presented.

Clinical Investigation of Burn Patients Transported by Helicopter Based on the Japan Trauma Data Bank.

OBJECTIVE: We retrospectively investigated the actual conditions of burn patients evacuated by helicopter in comparison to those evacuated by ground ambulance using the Japan Trauma Data Bank. METHODS: This study was a retrospective analysis of the data recorded in the Japan Trauma Data Bank between January 2004 and May 2019. After propensity score matching for the method of transportation, the survival rate was compared between the 2 groups. RESULTS: During the investigation period, there were 4,627 burn patients (helicopter group, n = 276; ambulance group, n = 4,351). After propensity score matching, there were no significant differences between the 2 groups in any of the assessed variables, and the survival rate did not differ to a statistically significant extent. CONCLUSION: After propensity score matching, the survival rate of the helicopter group did not appear to be superior to the ambulance group. Further prospective studies are needed to explore the proper indications for air transportation of burn patients, which could potentially improve outcomes.

Experience of the Usage of a Portable X-ray System.

OBJECTIVE: The purpose of this study was to introduce the use of a portable X-ray system by the staff members of a doctor helicopter (DH). METHODS: From January 11 to 18, 2019, we were given temporary access to a portable X-ray system. This period is defined as the investigation term. During the investigation term, a medical chart review was retrospectively performed for all patients who were transported by the DH. We investigated the variables between cases in which an X-ray study had been performed (X-ray group) and had not been performed (control group). RESULTS: Thirteen subjects were classified into the X-ray group, and 17 were classified into the control group. No X-ray studies were performed for patients who underwent interhospital transportation, and the proportion of cases involving patients with exogenous disease in the X-ray group was greater than that in the control group. CONCLUSION: We reported our experience of DH staff performing X-ray studies at the scene. Further studies are required to determine the indications for using portable X-ray systems in the prehospital setting.

Prognostic Factors in Trauma Patients Transported by Physician-Staffed Helicopter in Japan: An Investigation Based on the Japan Trauma Data Bank.

OBJECTIVE: We retrospectively investigated prognostic factors for patients evacuated by the physician-staffed helicopter emergency medical service using the Japan Trauma Data Bank. METHODS: The study period was from January 2004 to May 2019. The subjects were divided into 2 groups according to the outcome: the survival group and the fatal group. RESULTS: A total of 19,370 patients were enrolled as subjects. There were 17,080 patients in the survival group and 2,290 in the fatal group. In a multivariate analysis of factors that showed statistical significance in a univariate analysis, the Revised Trauma Score, age, Injury Severity Score, Maximum Abbreviated Injury Scale (MAX-AIS) for the upper extremity (negative), year of helicopter dispatch, Japan Coma Scale, MAX-AIS for the head, MAX-AIS for the abdomen/pelvis, and MAX-AIS for the spine were identified as significant predictors of a fatal outcome . CONCLUSION: This is the first report to investigate the prognostic factors of patients evacuated by helicopter emergency medical service using the Japan Trauma Data Bank. The results suggest that physiological abnormality, age, traumatic anatomic abnormality (other than upper extremity abnormality), and year of helicopter dispatch may be prognostic factors.

Regulatory T-cell dysfunction induces autoantibodies to bullous pemphigoid antigens in mice and human subjects.

BACKGROUND: Regulatory T (Treg) cells play a crucial role in peripheral immune tolerance in multiple organs, including the skin. Thus far, the effect of peripheral immune tolerance failure on autoantibody-related autoimmune reactions to the skin is unclear. OBJECTIVE: We sought to elucidate the target autoantigens in the skin under the condition of Treg cell dysfunction caused by forkhead box P3 (Foxp3) gene mutations in scurfy mice and patients with immunodysregulation, polyendocrinopathy, enteropathy, X-linked (IPEX) syndrome. METHODS: Sera and skin from scurfy mice and sera from patients with IPEX syndrome were analyzed to detect target autoantigens by using immunofluorescence studies, ELISAs, and immunoblotting. The pathogenicity of scurfy IgG was examined by using a passive transfer experiment. CD4+ T cells from scurfy mice were transferred to immunodeficient mice to examine their pathogenicity. Signal transducer and activator of transcription 6 (Stat6)-/- scurfy mice were analyzed to further clarify the molecular pathway of autoantibody production. Follicular helper T-cell counts are measured in Stat6-/- scurfy mice and scurfy mice. RESULTS: Scurfy mice spontaneously generated IgG autoantibodies to the dermal-epidermal junction, which had been class-switched from IgM within 12 days after birth. The target autoantigens were murine BP230 and type XVII collagen (COL17). The scurfy polyclonal autoantibodies did not induce skin fragility in neonatal mice. Autoantibody production was induced by CD4+ T cells from scurfy mice and was ameliorated by Stat6 gene knockout in association with a decrease of follicular helper T cells. We also identified autoantibodies to COL17 and BP230 in patients with IPEX syndrome and found an association between production of autoantibodies to COL17 and an eczematous skin phenotype. CONCLUSIONS: Dysregulation of Treg cells generates autoantibodies to COL17 and BP230 in vivo.

Convulsion Treated by a Physician-Staffed Helicopter.

OBJECTIVE: There have been no reports focusing on patients with convulsion treated by a doctor helicopter (DH). We herein report the results of a retrospective analysis investigating the changes in patients' vital signs and clinical manifestations during transportation and the outcomes of treating convulsive patients using a government-funded medical DH. METHODS: We retrospectively investigated all of the patients with convulsion who were transported by the DH between January 2013 and December 2018. RESULTS: A total of 118 cases were enrolled in the present study. The average age was 32 years old, and most were men. Fifty cases showed remaining convulsion when the staff of the DH made contact with the subject. All subjects obtained a survival outcome. Regarding anticonvulsants administered, diazepam was the most frequently used followed by midazolam. The frequency of convulsion after transportation was significantly lower than that before transportation. The Glasgow Coma Scale and peripheral capillary oxygen saturation after transportation to a hospital were higher than before transportation. The heart rate after transportation to a hospital was lower than before transportation. CONCLUSION: The present study indicated the usefulness of a physician-staffed helicopter for treating convulsive patients at the scene.