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Background: Fulminant myocarditis presentation (FMP) is a rare and severe presentation of myocarditis. The natural history of FMP and its clinical features associated with poor outcomes are incompletely understood because there is a lack of generalizable evidence. Methods: This multicenter retrospective cohort study included patients hospitalized with histologically proven myocarditis who underwent catecholamine or mechanical support from 235 cardiovascular training hospitals across Japan between April 2012 and March 2017. Clinical features and the prognostic predictors of death or heart transplantation within 90 days on the basis of clinical and pathologic findings were determined using the Kaplan-Meier method, log-rank test, and Cox regression analysis. Results: This study included 344 patients with histologically proven FMP (median age, 54 years; 40% female). The median follow-up was 600 days (interquartile range, 36 to 1599 days) and the cumulative risk of death or heart transplantation at 90 days was 29% (n=98). Results from multivariable Cox regression analysis showed that older age, nonsinus rhythm, low left ventricular wall motion ( Conclusions: The results from analyses of data from this multicenter registry demonstrated that patients with FMP are at a higher risk of death or heart transplantation in real-world settings. These observations inform which clinical and pathologic findings may be useful for prognostication in FMP. Registration: URL: https://www.umin.ac.jp/ctr ; Unique identifier: UMIN000039763.

Objectives We elucidate to investigate the prevalence of and factors associated with the use of physical restraints among critically ill or injured children in PICUs. Design This was a multicenter, longitudinal point prevalence study. Setting We included 26 PICUs in Japan. Patients Included children were 1 month to 10 years old. We screened all admitted patients in the PICUs on three study dates (in March, June, and September 2019). Intervention None. Measurements and main results We collected prevalence and demographic characteristics of critically ill or injured children with physical restraints, as well as details of physical restraints, including indications and treatments provided. A total of 398 children were screened in the participating PICUs on the three data collection dates. The prevalence of children with physical restraints was 53% (211/398). Wrist restraint bands were the most frequently used means (55%, 117/211) for potential contingent events. The adjusted odds of using physical restraint in patients 1-2 years old was 2.3 (95% CI, 1.3-4.0) compared with children less than 1 year old. When looking at the individual hospital effect, units without a prespecified practice policy for physical restraints management or those with more than 10 beds were more likely to use physical restraints. Conclusions The prevalence of physical restraints in critically ill or injured children was high, and significant variation was observed among PICUs. Our study findings suggested that patient age, unit size, and practice policy of physical restraint could be associated with more frequent use of physical restraints.

Staff are exposed to radiation in the scanning room when assisting with CT scans of patients requiring ventilatory support during procedures. We measured lens doses using a phantom during a high-energy trauma protocol. Dosimetry showed that the unprotected lens received 2.02 mGy on the right and 1.91 mGy on the left, which are not negligible doses. Respective exposures to the right and left lens were 53.6% and 55.1% when wearing 0.07 mm Pb protective glasses with side covers; 53.7% and 64.2% when wearing 0.7 mm Pb glasses without side covers when facing away from the patient couch; and 92.1% and 91.2% using protective shielding in the gantry. Since the face direction may change during assistance with CT imaging, it is desirable that the protective glasses have a shape with a side cover. The protective shielding had a major radiation reduction effect, although it is expensive to acquire, install, and maintain.

A 75-year-old man was admitted with abrupt onset of dyspnea during sleep. On examination, his blood pressure was 222/165 mm Hg, pulse was 160 bpm, and oxygen saturation was 75% while breathing ambient air. Heart sounds were difficult to assess because of coarse crackles and his moaning. There was no edema in the extremities. An ECG showed sinus tachycardia with a QRS duration of 111 milliseconds, and a chest radiograph showed pulmonary edema without cardiomegaly. A presumed diagnosis of acute heart failure was made, and isosorbide dinitrate was administered intravenously with supplemental oxygen via a face mask. Cardiac auscultation after stabilization of vital signs showed a holosystolic murmur at the apex and an early systolic click at the left sternal border. Mitral regurgitation resulting from mitral valve prolapse (MVP) was most likely but was not confirmed by transthoracic echocardiography because of a lack of definitive evidence (Figure 1). Of note, another extra sound during early diastole was heard best at the third left sternal border. Figure 1. Apical 2-chamber views of the left ventricle (LV) on transthoracic echocardiography show insufficient coaptation of the mitral leaflets ( A , arrow) and …

To outline the characteristics, clinical course, and outcome of pediatric patients requiring mechanical ventilation with influenza A/H1N1 infection in Japan.Prospective case registry analysis.Eleven pediatric or general intensive care units in Japan.Consecutive patients infected with A/H1N1, aged from 1 month to 16 yrs old admitted to the intensive care unit for mechanical ventilation between July 2009 and March 2010.None.Eighty-one children, aged 6.3 [0.8-13.6] (median [interquartile range]) years, were enrolled. Seventy-four (91%) had mechanical ventilation with tracheal intubation. Median duration of mechanical ventilation was 4 days (range 0.04-87) and 18 patients (23%) required mechanical ventilation7 days. Two patients (2%) required extracorporeal membrane oxygenation. The in-hospital mortality was 1%. Forty-one patients (50%) had at least one underlying chronic condition, including 31 with asthma. Associated clinical symptoms and diagnosis were as follows: acute respiratory distress syndrome (9%), asthma or bronchitis (37%), pneumonia (68%) with 8 (14%) having bacterial pneumonia, neurological symptoms (32%), myocarditis (2%), and rhabdomyolysis (1%). Therapeutic interventions include inotropic support (21%), methylprednisolone therapy (33%), and antimicrobial therapy (88%). Multivariate analysis revealed that inotropic support was the only statistically significant factor associated with mechanical ventilation for more than a week (odds ratio 5.5, 95% confidence interval 1.5-20.5, p = .005).The clinical presentations of pediatric patients requiring mechanical ventilation for A/H1N1 in Japan were diverse. In-hospital mortality of this population was remarkably low. Rapid access to medical facilities in combination with early administration of antiviral agents may have contributed to the low mortality in this population.

To the Editor:“Sepsis-3,” a new definition for sepsis and septic shock proposed in early 2016 (1), dramatically impacted on the critical care community around the world to change the concept of sepsis and septic shock from “systemic inflammatory response due to infection” to “acute and potentially l

Patients with hypertrophic cardiomyopathy sometimes develop extreme hypertrophy in the left ventricle. A 78-year-old woman showed rapid progression of left ventricular hypertrophy. She was referred to our hospital at the age of 73 years because of left ventricular hypertrophy on seen on ECG. …

A 75-year-old man with a history of coronary artery bypass surgery was referred for evaluation of dyspnea and chest discomfort. He underwent myocardial perfusion imaging with 600 MBq (16.2 mCi) Tc-99m tetrofosmin at rest, followed 30 minutes later by whole-body planar imaging. Imaging revealed skeletal uptake throughout. Subsequent bone marrow biopsy revealed multiple myeloma. This finding is probably attributable to a hyperactive bone turnover rate occurring secondary to multiple myeloma.

A longer filling interval induces better ventricular filling and subsequently stronger contraction. This phenomenon is often observed after a premature ventricular contraction and is called postextrasystolic potentiation. The following three-dimensional perfusion images show visualization of postextrasystolic potentiation induced by ventricular trigeminy.