[A Case of Interstitial Pneumonia Induced by Immune Checkpoint Inhibitors for Gastric Cancer During the COVID- 19 Pandemic].

BACKGROUND: The novel coronavirus disease(corona virus disease 2019: COVID-19)has calmed down worldwide, and the severity of the disease is decreasing. On the other hand, due to the emergence of strain mutations, the number of infected people shows a wavy course. I have experienced a case of gastric cancer that underwent chemotherapy including an immune checkpoint inhibitors(ICI) early after COVID-19, so I will report it including a discussion. CASE: A 71-year-old man. The patient visited our hospital with a chief complaint of stomach discomfort, and gastrointestinal endoscopy revealed advanced gastric cancer accompanied by narrowing of the gastric lumen. The histopathological examination showed a poorly differentiated adenocarcinoma. A CT scan of the chest and abdomen showed thickening of the entire gastric wall, indicating the presence of enlarged adjacent lymph nodes and infiltration into adjacent organs. No other obvious distant metastases were observed. Staging laparoscopy was performed, it revealed infiltration of the posterior wall of the stomach into the celiac artery and anterior surface of the pancreas. We determined that curative resection would be difficult. As a result of planning chemotherapy for locally advanced gastric cancer, the patient contracted COVID-19 due to a hospital- acquired infection. The patient's COVID-19 infection was managed with supportive care alone without severe complications, and they recovered within the course of treatment. Two weeks after the onset of the infection, chemotherapy(FOLFOX+ Nivo)was initiated. The patient completed up to 9 courses of chemotherapy, and the treatment response was determined to be stable disease(SD). Due to a tendency of stenosis in the gastric lumen, the possibility of future dilation procedures was considered. As a result, the patient underwent second-line chemotherapy with a combination of wPTX+RAM. After completing 1 course of treatment, the patient developed drug-induced interstitial pneumonia, which was managed with intensive care and steroid pulse therapy, resulting in improvement. There was progression of gastric lumen stenosis, and an endoscopic dilation procedure/stent placement was performed. Subsequently, there was a rapid increase in malignant ascites and a decline in activities of daily living(ADL), leading to palliative care. Unfortunately, the patient succumbed to cancer-related complications 10 months after the diagnosis. DISCUSSION: In this case, the serial antibody titers of COVID-19 also indicated the sustained effectiveness of the multi-drug combination chemotherapy. The treatment course suggests a suspicion of drug-induced interstitial pneumonia due to PTX/RAM, but the long-term imaging follow-up implies that ICI may be the cause. When using ICI, COVID-19 infection alone may pose a potential risk factor.

Characteristics of high-echoic objects in the hepatic vessels of patients with cardiopulmonary arrest: a prospective cohort study.

BACKGROUND: High-echoic objects in the hepatic vessels of patients with cardiopulmonary arrest (CPA) are frequently detected by ultrasonography. OBJECTIVE: To demonstrate this phenomenon and clarify its clinical characteristics. METHODS: In a tertiary care academic medical centre, 203 CPA patients were evaluated by ultrasonography. CT determined the origin and location of high-echoic objects detected in the liver. The frequency and characteristics of this phenomenon were investigated. The background, laboratory data and survival rate were compared between patients with and without high-echoic objects. RESULTS: High-echoic objects were seen in 73 (36.0%) patients and could clearly be detected in the hepatic veins of 41 (56.2%) patients. CT confirmed that these were gas in 27 of 53 patients, and were clearly visible in the hepatic veins in 12 (44.4%) patients. Hepatic portal venous gas was not identified. Compared to patients without high-echoic objects, witnessed arrest (p<0.001), bystander cardiopulmonary resuscitation (p=0.005), ventricular fibrillation or pulseless electrical activity (p=0.012) and return of spontaneous circulation (p=0.018) were significantly less frequent in patients with high-echoic objects. These patients had a lower incidence of survival to discharge (1.4% vs 7.7%, p=0.100). Multivariate analysis showed that absence of high-echoic objects was a marginally significant factor in association with return of spontaneous circulation (p=0.052). CONCLUSIONS: High-echoic objects were often observed on ultrasonography in CPA patients; these objects were considered hepatic venous gas. The presence of high-echoic objects may be a poor prognostic sign in patients with CPA.

[Retropharyngo-esophageal hematoma treated by open paramedian tracheostomy].

Forty eight year-old woman with untreated liver cirrhosis was transferred to our critical care and emergency center because of airway crisis due to retropharyngo-esophageal hematoma after slight chest contusion. We performed emergency tracheal intubation beyond stenotic part of the trachea. The hematoma did not diminished in a few days. Although we considered tracheostomy, we hesitated to perform conventional median tracheostomy because of the risk of complication of infection of the hematoma which might require drainage or removal resulting in contamination between tracheostomy site and cervical wound. We performed paramedian tracheostomy by antero-lateral skin incision to avoid these risks. Fortunately, the patient did not require drainage of the retropharyngo-esophageal hematoma. Paramedian tracheostomy should be taken into account for patients with presumably contaminated cervical wound.

Association between Survival Duration of Older Patients with Advanced Unresectable Pancreatic Cancer and Appetite Loss: A Retrospective Cohort Study.

This retrospective cohort study clarified associations between trajectories in palliative care and appetite loss among older patients with advanced unresectable pancreatic cancer and reviewed pancreatic cancer diagnosis among these populations in rural community hospitals. Patients aged >65 years and with pancreatic cancer in a rural community hospital were enrolled. The primary outcome was survival duration from the time of pancreatic cancer diagnosis. Participants were divided into those with and without appetite loss. Cumulative event-free survival rates were calculated using the Kaplan−Meier method, analyzed using the log-rank test, and stratified by factors with statistically significant between-group differences (serum albumin). The mean participant age was 84.14 (SD, 8.34) years; 31.4% were men. Significant between-group differences were noted in albumin concentration and survival duration. Kaplan−Meier curves showed a significant between-group difference in survival probability (p < 0.001). Survival duration significantly differed after stratification by albumin level (p < 0.001). Appetite loss may be a useful symptom for predicting mortality among older patients with unresectable pancreatic cancer, and hypoalbuminemia may accelerate deterioration in their conditions. Accordingly, subjective appetite loss observed by patients and families should be assessed to predict mortality, and it is advisable for physicians to promptly discuss relevant and advanced directives at appropriate timings.

Outcomes from prehospital cardiac arrest in blunt trauma patients.

BACKGROUND: There are few strategies for treating patients who have suffered cardiopulmonary arrest due to blunt trauma (BT-CPA). The aim of this population-based case series observational study was to clarify the outcome of BT-CPA patients treated with a standardized strategy that included an emergency department thoracotomy (EDT) under an emergency medical service (EMS) system with a rapid transportation system. METHODS: The 477 BT-CPA registry data were augmented by a review of the detailed medical records in our emergency department (ED) and action reports in the prehospital EMS records. RESULTS: Of those, 76% were witnessed and 20% were CPA after leaving the scene. In all, 18% of the patients went to the intensive care unit (ICU), the transcatheter arterial embolization (TAE) room, or the operating room (OR). Only 3% survived to be discharged. Among the 363 witnessed patients-11 of whom had ventricular fibrillation (VF) as the initial rhythm, 134 exhibiting pulseless electrical activity (PEA), and 221 with asystole-13, 1, and 3%, respectively, survived to discharge. The most common initial rhythm just after collapse was not VF but PEA, and asystole increased over the 7 min after collapse. There were no differences in the interval between arrival at the hospital and the return of spontaneous circulation between the patients that survived to discharge and deceased patients in the ED, OR, TAE room, or ICU. The longest interval was 17 min. CONCLUSIONS: In BT-CPA patients, a 20-min resuscitation effort and termination of the effort are thought to be relevant. The initial rhythm is not a prognostic indicator. We believe that the decision on whether to undertake aggressive resuscitation efforts should be made on a case-by-case basis.

Strengths and Challenges for Medical Students and Residents in Rural Japan.

BACKGROUND AND OBJECTIVES: In Japan, family medicine training is driven by community-based medical education (CBME) and is often provided in rural community hospitals and clinics. Although CBME's positive relationship to family medicine in rural community hospitals is proven, the learning processes of medical students and residents in rural community hospitals needs investigating. The objective of this study was to reveal medical students' and residents' changing motivations and learning behaviors, as well as the factors underpinning their transition between medical schools or tertiary hospitals and rural community hospitals. METHODS: Over 2 years, the researchers conducted one-on-one interviews with 50 medical students and 30 residents participating in family medicine training at a rural community hospital, and analyzed the difficulties the participants encountered and how they overcame them. The interviews were audio recorded and transcribed verbatim. We used grounded theory in the data analysis to clarify the findings. RESULTS: Three key themes emerged: educational background, changing environment, and factors driving the learning cycle. Participants had difficulties in overcoming differences between their previous education and their CBME, particularly regarding expected roles and the variety of medical issues. They overcame their difficulties through cognitive apprenticeships and legitimate peripheral participation enhanced by daily reflection. CONCLUSIONS: In rural community hospitals, participants struggled to adapt to the wider practice range and the more interactive relationship with educators. Cognitive apprenticeships and legitimate peripheral participation, supported by constant reflection between learners and clinical teachers, can facilitate learning, leading to more effective learning and practice of family medicine in rural areas.

Comprehensive Care through Family Medicine: Improving the Sustainability of Aging Societies.

Comprehensive care through family medicine can enhance the approach to multimorbidity, interprofessional collaboration, and community care, and make medical care more sustainable for older people. This study investigated the effect of implementing family medicine and the comprehensiveness of medical care in one of the most rural communities. This implementation research used medical care data from April 2015 to March 2020. Patients' diagnoses were categorized according to the 10th revision of the International Statistical Classification of Disease and Related Health Problems (ICD-10). In 2016, family medicine was implemented in only one general hospital in Unnan. The comprehensiveness rate improved in all ICD-10 disease categories during the study period, especially in the following categories-infections; neoplasms; endocrine, nutritional, and metabolic diseases; mental disorders; nervous system; circulatory system; respiratory system; digestive system; skin and subcutaneous tissue; musculoskeletal system and connective tissue; and the genitourinary system. Implementing family medicine in rural Japanese communities can improve the comprehensiveness of medical care and resolve the issue of fragmentation of care by improving interprofessional collaboration and community care. It can be a solution for the aging of both patient and healthcare professionals. Future research can investigate the relationship between family medicine and patient health outcomes for improved healthcare sustainability.

Effect of fasting on coagulation factors in patients who undergo major abdominal surgery.

Major abdominal surgery without preoperative adequate oral intake with some cephalosporins may result in vitamin K deficiency and bleeding tendency. The aim of this study is to clarify the effect of preoperative fasting on postoperative coagulation factors. We prospectively examined 16 patients who underwent major abdominal surgery. Patients were divided into a preoperative fast group (Group F, n = 7, mean period of preoperative fasting 8.7 days) and a control group (Group C, n = 9). We did not administer vitamin K and initiated feeding after the seventh postoperative day. In Group C, prothrombin time (PT) and Factors II, VII, IX, and X levels were decreased after the surgery to within normal limits. In Group F, the PT and Factors II, VII, and X levels were decreased after the surgery. Abnormal lower levels of PT and Factors II, VII, and X were seen in 67, 33, 67, and 67 per cent of patients after the surgery, respectively. Factors VII and X levels were higher than in Group C by the third postoperative day. The protein induced by vitamin K absence or antagonist-II levels in Group F were increased at all postoperative points. Clinicians should realize that preoperative fasting for as little as 1 week can induce precoagulopathy, resulting in postoperative coagulopathy after major surgery.

Usefulness and safety of open tracheostomy by a paramedian approach for cervical infection: esophageal and tracheal injury and necrotizing fascitis.

Tracheostomy is hardly performed in patients with cervical infection close to the site of the tracheostomy. This study aimed to present and clarify the usefulness and safety of open tracheostomy performed by the paramedian approach technique. The procedure is as follows. A 2.5-cm paramedian incision is made for the tracheostomy on the opposite side of infectious focus; the anterior neck muscles are dissected and split; the trachea is fenestrated by a reverse U-shaped incision; and the fenestral flap of the trachea is fixed to the skin. We used this technique in five patients. There were no complications such as bleeding, desaturation, and displacement of the tube; and there were no postoperative complications such as severe contamination or infection of the tracheostomy site from the nearby cervical wound, difficulty in securing the tracheostomy tube and connecting device to the ventilator, difficulties in daily management and care, or dislocation of the tracheostomy tube. All wounds resulting from the tracheostomy were kept separate from and not contaminated by the nearby dirty wounds. Open tracheostomy by the paramedian approach technique is useful and safe for patients with severe cervical infection requiring open drainage and long ventilatory management.

A new concept for stage grouping of gastric cancer according to dynamic stage migration with time: a survival-period perspective.

The aim of this study was to clarify the mechanism of "dynamic stage migration with time". Nine hundred thirty-nine patients with gastric cancer were evaluated in the study. Patients who survived for more than 1, 2, 3, 4, and 5 years after the initial operation were selected. The 6-, 7-, 8-, 9-, and 10-year survival rates from the time of surgery were evaluated for every tumor depth (t)/nodular status (n) group in every stage. The longer the patients survived after the initial operation, the closer the next 5 year survival of patients in the t2n0 group came to that of patients in the t1n0 group; the closer that of t2n1 patients came to that of t1n1; and the closer those of t3n2, t2n2, t2n3, and t3n1 patients came to that of t3n0 patients. A stage grouping at some years after the initial operation is expected to differ from that estimated just after surgery because of the heterogeneity of the disease.

How frequently do we encounter polytrauma patients with conscious disorder without intracranial hemorrhagic injury?

The purpose of this study was to clarify the rate and characteristics of conscious disorder without intracranial hemorrhagic injury in polytrauma patients. The medical records of polytrauma patients with conscious disorder without intracranial hemorrhagic injury were reviewed. Fifty-five patients (35.3% of 156 polytrauma patients with conscious disorder) were enrolled. Admission Glasgow Coma Scale (GCS) score was 15 in 34%, 14 in 22%, and less than 8 in 13%. In 39 patients (70.9%), clear causes of conscious disorder (alcohol and shock) were evident. A high rate of conscious disorder derived from shock was noted in the more severe conscious disorder categories. Conscious disorder due to alcohol was likely seen in patients whose GCS scores were 13 and 14. The rate of conscious disorder without intracranial hemorrhagic injury was high among polytrauma patients. We could not differentiate the pattern of conscious disorder in polytrauma patients without intracranial hemorrhagic injury from that seen in polytrauma patients with intracranial hemorrhagic injury.

Treatment of hepatic encephalopathy by on-line hemodiafiltration: a case series study.

BACKGROUND: It is thought that a good survival rate of patients with acute liver failure can be achieved by establishing an artificial liver support system that reliably compensates liver function until the liver regenerates or a patient undergoes transplantation. We introduced a new artificial liver support system, on-line hemodiafiltration, in patients with acute liver failure. METHODS: This case series study was conducted from May 2001 to October 2008 at the medical intensive care unit of a tertiary care academic medical center. Seventeen consecutive patients who admitted to our hospital presenting with acute liver failure were treated with artificial liver support including daily on-line hemodiafiltration and plasma exchange. RESULTS: After 4.9 +/- 0.7 (mean +/- SD) on-line hemodiafiltration sessions, 16 of 17 (94.1%) patients completely recovered from hepatic encephalopathy and maintained consciousness for 16.4 +/- 3.4 (7-55) days until discontinuation of artificial liver support (a total of 14.4 +/- 2.6 [6-47] on-line hemodiafiltration sessions). Significant correlation was observed between the degree of encephalopathy and number of sessions of on-line HDF required for recovery of consciousness. Of the 16 patients who recovered consciousness, 7 fully recovered and returned to society with no cognitive sequelae, 3 died of complications of acute liver failure except brain edema, and the remaining 6 were candidates for liver transplantation; 2 of them received living-related liver transplantation but 4 died without transplantation after discontinuation of therapy. CONCLUSIONS: On-line hemodiafiltration was effective in patients with acute liver failure, and consciousness was maintained for the duration of artificial liver support, even in those in whom it was considered that hepatic function was completely abolished.

[Experience of damage control as the primary surgery for thoraco-abdominal injury with hemorrhagic shock].

We experienced a traumatic victim with thoracic and abdominal injury with hemorrhagic shock, who was successfully treated with damage control. Thoracic drainage revealed more than 300 ml/hour of continuous hemorrhage in the left thoracic cavity with 60-80 mmHg of non-responding hypotention. Although we performed emergency partial resection of the injured lung, intraabdominal packing and transcatheter arterial embolization, intrathoracic hemorrhage and hemorrhagic shock was not controlled. We decided re-thoracotomy and performed peri-pulmonary packing around the injured lung, by which we successfully controlled temporary intrathoracic hemorrhage and definitive left lower lobectomy. Peri-pulmonary packing was effective for intrathoracic hemostasis without lethal ventilatory and circulatory complication in this case.

A case of acute superior mesenteric arterial occlusion with successful emergency simultaneous side-to-end anastomosis.

A 72-year-old woman was transferred to our critical care center because of transient loss of consciousness and aphasia. She had a history of abdominal pain, nausea, and atrial fibrillation, and reported on admission mild abdominal rebound tenderness, inflammatory response, acidosis and renal dysfunction. We suspected acute superior mesenteric arterial occlusion (SMAO) after cerebral infarction. We performed simultaneous reconstruction with side-to-end anastomosis using circular and linear staplers, rather than jejunostomy, which avoided the loss of massive intestinal contents and frequent diarrhea. A detailed history is important to make a diagnosis of acute SMAO and simultaneous reconstruction with side-to-end anastomosis is an important treatment option.

Lethal obstructive colitis: how and when patients with colonic obstruction should be prevented from falling into a lethal condition.

BACKGROUND/AIMS: The objective of this study is to clarify the pathological condition and treatment strategy of lethal obstructive colitis (LOC), which is defined as obstructive colitis with severe shock or septic shock. METHODOLOGY: We examined 5 patients with LOC (colorectal cancer or suspected in 2, fecal impaction in 2, and volvulus in 1) and evaluated their pathophysiology and management strategy from their medical records. RESULTS: Emergency operations were performed within 150 minutes from arrival in all cases. Three were saved by repeat operations and 2 died. The systolic pressure of both survived and deceased patients were under 62 or palpable only on the common carotid artery, and there was no difference between survived and deceased patients. The mean pulse rate of the deceased patients was 76.5 while survived 117.7. Two deceased patients presented unconsciousness or conscious disorder while survived patients showed clear consciousness. The 2 deceased patients fell into VT just after arrival or during the operation. CONCLUSIONS: In managing colonic obstruction, we should be aware of this potentially lethal disease and surgical treatment should be performed as soon as possible before the patients fall into LOC. Early diagnosis and early aggressive surgery is essential for managing LOC.

Severe anemia inducing preshock caused by sarcomatoid carcinoma of the small intestine.

A 55-year-old man consulted the outpatient department because of shortness of breath on effort and palpitation. Clinical examination showed severe anemia, a tumor with an ulcer on jejunography, with isodensity in contrast enhancement computed tomography, and a tumor stain on angiography, with middle intensity in T1- and T2-weighted images on magnetic resonance imaging. During laparotomy, we found jejunal tumors and lymph node swelling (TMN stage T3 N4 M1), and we performed a partial resection of the jejunum. Pathological examination showed a sarcomatoid carcinoma extending to the subserosal layer with multiple nodal metastases. The tumor was composed mainly of sheets of spindle cells and partially anaplastic cells appearing to be of epithelial cell origin. Histochemical staining showed a negative reaction for leukocyte common antigen and UCHL-1 and a weakly positive reaction for cytokeratin and epithelial membrane antigen. The patient died on postoperative day 283.

Lethal perianal infection with septic shock: how should we manage this critical condition?

Some patients with perianal infection fall into a critical condition with severe sepsis and septic shock (lethal perianal infection). The objective of this study is to clarify the clinicopathological characteristics of, and treatment strategies for, lethal perianal infection. The clinical records of 7 patients with lethal perianal infection were examined. For two rapidly dying cases (within 3 days), we performed resection of the rectum or local anal drainage as a primary management of damage control. These patients were transferred to our center because of septic shock and multiple organ dysfunction syndrome (MODS) and had received insufficient fluid resuscitation in the previous hospital. Another nonsurviving case who died on the 16th day was transferred without MODS and underwent perianal drainage but could not recover from shock, even after repeated surgical procedures were performed. To prevent a perianal infection from becoming lethal, it should be managed as early as possible with sufficient fluid resuscitation with adequate drainage.

Evaluation of an algorithm for estimating a patient's life threat risk from an ambulance call.

BACKGROUND: Utilizing a computer algorithm, information from calls to an ambulance service was used to calculate the risk of patients being in a life-threatening condition (life threat risk), at the time of the call. If the estimated life threat risk was higher than 10%, the probability that a patient faced a risk of dying was recognized as very high and categorized as category A+. The present study aimed to review the accuracy of the algorithm. METHODS: Data collected for six months from the Yokohama new emergency system was used. In the system, emergency call workers interviewed ambulance callers to obtain information necessary to assess triage, which included consciousness level, breathing status, walking ability, position, and complexion. An emergency patient's life threat risk was then estimated by a computer algorithm applying logistic models. This study compared the estimated life threat risk occurring at the time of the emergency call to the patients' state or severity of condition, i.e. death confirmed at the scene by ambulance crews, resulted in death at emergency departments, life-threatening condition with occurrence of cardiac and/or pulmonary arrest (CPA), life-threatening condition without CPA, serious but not life-threatening condition, moderate condition, and mild condition. The sensitivity, specificity, predictive values, and likelihood ratios of the algorithm for categorizing A+ were calculated. RESULTS: The number of emergency dispatches over the six months was 73,992. Triage assessment was conducted for 68,692 of these calls. The study targets account for 88.8% of patients who were involved in triage calls. There were 2,349 cases where the patient had died or had suffered CPA. The sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio and negative likelihood ratio of the algorithm at predicting cases that would result in a death or CPA were 80.2% (95% confidence interval: 78.6% - 81.8%), 96.0% (95.8% - 96.1%), 42.6% (41.1% - 44.0%), 99.2% (99.2% - 99.3%), 19.9 (18.8 - 21.1), and 0.21 (0.19 - 0.22), respectively. CONCLUSION: A patient's life threat risk was quantitatively assessed at the moment of the emergency call with a moderate level of accuracy.

Students' perceptions of general medicine following community-based medical education in rural Japan.

BACKGROUND: Japan's population is rapidly aging, and at the same time, the number of medical students interested in general or family medicine is declining. Community-based medical education (CBME) programs may be used to promote interest and competencies in general medicine among medical students. METHOD: This mixed-method study investigated the perceptions of fifth- and sixth year undergraduate medical students who completed a two week CBME course in Unnan, a small city in rural Japan. The participants completed two survey questionnaires: (a) The achievement questionnaire administered pre- and posttraining, and (b) the curriculum content questionnaire administered posttraining. To understand the students' perceptions about general medicine further, semistructured interviews were conducted with each participant post-CBME training. RESULTS: The participants' ratings on the achievement survey improved significantly from pre- to posttraining. The average ratings for the curriculum content survey indicated that the educational objectives were met in all but one area. A qualitative analysis of the interview data revealed that the participants had little exposure to general medicine at their university hospital, and there was a lack of understanding in other medical professionals regarding the roles of general medicine physicians. CONCLUSION: This study demonstrates that there are educational gaps between medical universities and community hospitals regarding general medicine. Increased exposure, early exposure, and a clarification of the competencies were noted as areas to improve the students' understanding of general medicine. Undergraduates should be exposed to general medicine more frequently and from early training stages through effective collaborations between universities and hospitals.