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BACKGROUND Acute coronary syndrome is life-threatening. The diagnosis can be confirmed by electrocardiography (ECG) and serum cardiac biomarkers. Early diagnosis and treatment of non-ST segment elevation myocardial infarction (NSTEMI) is important because delayed treatment is associated with poor prognosis, especially in older adults. CASE REPORT An 82-year-old woman presented to the Emergency Department (ED) with epigastric and back pain. Despite the symptoms, the electrocardiogram revealed no abnormality, and the high-sensitivity cardiac troponin (Hs-cTn) value was below the detection limit. Chest contrast-enhanced computed tomography (CT) performed to exclude fatal diseases such as aortic dissection revealed no obvious abnormalities. The patient's symptoms improved and she was discharged. On the following day, the radiologist reviewed the CT and noted reduced cardiac uptake of contrast medium, and so suspected a subendocardial infarction. The patient was immediately recalled to the ED. She had no symptoms, but her Hs-cTn level was markedly elevated and asynergy was found on echocardiography. Emergency coronary angiography revealed complete obstruction of the left anterior descending coronary artery. CONCLUSIONS Similar to patients with acute ST segment elevation myocardial infarction, those with unstable angina or NSTEMI should be treated early. Delayed diagnosis and treatment of acute coronary syndrome is associated with poor prognosis, especially in older adults. Therefore, in patients presenting to the ED with chest pain, careful attention should be paid to myocardial staining in addition to the aorta, pulmonary arteries, and abdominal organs, when performing contrast-enhanced CT.

Blind nasogastric (NG) is inserted for patients under resuscitation, however minimal trauma to the laryngopharynx can sometimes lead severe bleeding. Recently, NG tube placement under the assistance of a Video-laryngoscope (VLS) has reported. We investigated laryngopharyngeal mucosal injury associated with blind NG tube insertion and considered practical blind NG tube insertion. Patients with cardio pulmonary arrest in whom blind nasogastric tube insertion was possible within 120 s in the Blind group and those in whom it was not possible in the Difficult (Dif) group. In the Dif group, VLS-assisted NG tube insertion was performed. Success rates, insertion time, number and laryngopharyngeal mucosal injury scores were compared. Success rates in the Blind and Dif groups were 98.5% and 76.5%, and insertion times were 48.8 ± 4.0 and 54.8 ± 3.0 s, respectively. The number of insertions and injury scores in the Blind group were significantly lower than those in the Dif group, respectively. The number of insertions and insertion time both showed strong positive correlations with injury scores. Blind NG tube insertion performed within 1 min or for a maximum of two or three attempts may minimize laryngopharyngeal mucosal injury, and VLS-assisted insertion should be considered if these limits are exceeded.

Background: Patients under resuscitation are at high risk for aspiration of gastric contents which causes ventilator-associated pneumonia. Therefore, blind nasogastric (NG) insertion is performed for decompression, however minimal trauma to the laryngopharynx can sometimes lead to severe bleeding in patients with a bleeding diathesis. Recently, the usefulness of NG tube placement under the assistance of a Video-laryngoscope (VLS) has reported. However, NG tube insertion is still performed blind, and insertion techniques to minimize mucosal injury during resuscitation are not well understood. We investigated laryngopharyngeal mucosal injury associated with blind NG tube insertion during resuscitation and considered practical blind NG tube insertion guidelines to minimize mucosal injury. Methods: We included patients (n = 84) with cardio pulmonary arrest on arrival in whom blind nasogastric tube insertion was possible within 120 s in the Blind group and those in whom it was not possible in the Difficult (Dif) group. In the Dif group, VLS-assisted nasogastric tube insertion was performed. The laryngopharyngeal mucosal condition was recorded after NG tube insertion using VLS. Patient background, success rates, insertion time, the number of insertions, and injury scores were evaluated. A single regression analysis was performed, and practical blind NG tube parameters for insertion during resuscitation were assessed. Results: Success rates in the Blind and Dif groups were 98.5% and 76.5%, respectively, and insertion times were 48.8 ± 4.0 and 54.8 ± 3.0 s, respectively. The number of insertions (2.1 ± 0.2 vs. 8.1 ± 0.8) and injury scores (1.04 ± 0.21 vs. 6.40 ± 0.64) in the Blind group were significantly lower than those in the Dif group, respectively. Mucosal injuries were most severe in the retropharyngeal wall in both groups. The number of insertions and insertion time both showed strong positive correlations with injury scores.Conclusion: The severity of laryngopharyngeal mucosal injury increased with increased insertion time and the number of insertions. Blind nasogastric tube insertion performed within 1 min or for a maximum of two or three attempts may minimize laryngopharyngeal mucosal injury, and VLS-assisted insertion should be considered if these limits are exceeded.

Global warming increases the incidence of heatstroke. After heatstroke, patients are bedridden and exhibit neurological symptoms suggesting cerebellar damage. However, the potential long-term adverse outcomes are poorly understood. We studied the cerebellum after heatstroke. In our study, motor coordination disorder significantly appeared 3 weeks post heatstroke and gradually improved to some extent over time. Demyelination was detected at 1 and 3 weeks after heatstroke at the cerebellum. Interestingly, it was not found at the corpus callosum. The Purkinje cell numbers significantly decreased at 1-, 3-, and 9-weeks post heatstroke. The intensity of synaptophysin and postsynaptic density-95 (PSD95) temporarily decreased at 3 weeks post heatstroke; however, both increased at 9 weeks post heatstroke. Motor coordination loss occurred a few weeks after heatstroke and recovered to some extent. Late-onset motor impairment was suggested to be caused by cerebellar dysfunctions that were morphologically assessed by myelin staining and immunostaining of Purkinje cells with pre-and postsynaptic markers. However, the Purkinje cell number did not recover for 9 weeks, the others, including motor coordination were partially recovered probably by synaptic reconstruction, residual Purkinje cells, and other cerebellar neuron remyelination. These phenomena were associated with late-onset neurological deficits and recovery after heatstroke.

Adhesion is a common complication following surgical repair of flexor tendons, resulting in the restriction of tendon gliding. We investigated the effect of early exercise on adhesion formation. To create an adhesion model, the proximal region of the second phalanx of the third toe in 4-month-old White Leghorn chickens was cut. The gliding side of the flexor digitorum profundus was hemiresected and the bony floor was crushed to enhance adhesion formation. The resected area was fixed in an extended position for 1, 2, or 3 weeks. Following 1, 2, or 3 weeks of active exercise, the chickens were sacrificed and morphological changes in the adhesions were assessed. In the 1- and 2-week fixed groups, 1, 2, or 3 weeks of active exercise resulted in mesotenon-like adhesion that was elastic and had no effect on tendon gliding. However, in the 3-week fixed group, a mature adhesion remained with limited change and tendon gliding was inhibited even after 3 weeks of active exercise. Thus, we concluded that adhesions become more elastic with early exercise within 2 weeks after tendon repair, but that adhesions following tendon repair tend not to show any further elastic changes when exercise is started 3 weeks after the repair.

To assess heat stroke and heat exhaustion occurrence and response during the coronavirus disease 2019 pandemic in Japan.This retrospective, multicenter, registry-based study describes and compares the characteristics of patients between the months of July and September in 2019 and 2020. Factors affecting heat stroke and heat exhaustion were statistically analyzed. Cramér's V was calculated to determine the effect size for group comparisons. We also investigated the prevalence of mask wearing and details of different cooling methods.No significant differences were observed between 2019 and 2020. In both years, in-hospital mortality rates just exceeded 8%. Individuals65 years old comprised 50% of cases and non-exertional onset (office work and everyday life) comprised 60%-70%, respectively. The recommendations from the Working Group on Heat Stroke Medicine given during the coronavirus disease pandemic in 2019 had a significant impact on the choice of cooling methods. The percentage of cases, for which intravascular temperature management was performed and cooling blankets were used increased, whereas the percentage of cases in which evaporative plus convective cooling was performed decreased. A total of 49 cases of heat stroke in mask wearing were reported.Epidemiological assessments of heat stroke and heat exhaustion did not reveal significant changes between 2019 and 2020. The findings suggest that awareness campaigns regarding heat stroke prevention among the elderly in daily life should be continued in the coronavirus disease 2019 pandemic. In the future, it is also necessary to validate the recommendations of the Working Group on Heatstroke Medicine.

Since the 2000s, "intracranial hypotension syndrome associated with trauma" has become a social problem in relation to litigation and compensation issues in Japan. To address this problem, guidelines for correct diagnosis have been developed. The basic pathogenesis of this disease is cerebrospinal fluid leakage caused by fragile tissue injury due to trauma. In order to improve the treatment outcome of this disease, it is important to prove the CSF leakage directly, using diagnostic imaging based on the guidelines, rather than diagnosing it based on clinical manifestations alone. For management, an epidural blood patch(EBP)should be used only after careful consideration. As such, rest and adequate fluid replacement should generally be given first. However, in cases with concomitant subdural hematoma, the order of hematoma irrigation and EBP should be determined according to the condition and urgency of each patient. In addition, it is necessary to standardize the formal name of this condition in papers to ensure rigorous academic discussion.

Background Frailty has been associated with a risk of adverse outcomes, and mortality in patients with various conditions. However, there have been few studies on whether or not frailty is associated with mortality in patients with accidental hypothermia (AH). In this study, we aim to determine this association in patients with AH using Japan’s nationwide registry data. Methods The data from the Hypothermia STUDY 2018&19, which included patients of ≥18 years of age with a body temperature of ≤35 °C, were obtained from a multicenter registry for AH conducted at 120 institutions throughout Japan, collected from December 2018 to February 2019 and December 2019 to February 2020. The clinical frailty scale (CFS) score was used to determine the presence and degree of frailty. The primary outcome was the comparison of mortality between the frail and non-frail patient groups. Results In total, 1363 patients were included in the study, of which 920 were eligible for the analysis. The 920 patients were divided into the frail patient group (N = 221) and non-frail patient group (N = 699). After 30-days of hospitalization, 32.6% of frail patients and 20.6% of non-frail patients had died (p p p Conclusions This study showed that frailty was associated with mortality in patients with AH. Preventive interventions for frailty may help to avoid death caused by AH.

In this study, we aimed to develop and validate a machine learning-based mortality prediction model for hospitalized heat-related illness patients. After 2393 hospitalized patients were extracted from a multicentered heat-related illness registry in Japan, subjects were divided into the training set for development (n = 1516, data from 2014, 2017–2019) and the test set (n = 877, data from 2020) for validation. Twenty-four variables including characteristics of patients, vital signs, and laboratory test data at hospital arrival were trained as predictor features for machine learning. The outcome was death during hospital stay. In validation, the developed machine learning models (logistic regression, support vector machine, random forest, XGBoost) demonstrated favorable performance for outcome prediction with significantly increased values of the area under the precision-recall curve (AUPR) of 0.415 [95% confidence interval (CI) 0.336–0.494], 0.395 [CI 0.318–0.472], 0.426 [CI 0.346–0.506], and 0.528 [CI 0.442–0.614], respectively, compared to that of the conventional acute physiology and chronic health evaluation (APACHE)-II score of 0.287 [CI 0.222–0.351] as a reference standard. The area under the receiver operating characteristic curve (AUROC) values were also high over 0.92 in all models, although there were no statistical differences compared to APACHE-II. This is the first demonstration of the potential of machine learning-based mortality prediction models for heat-related illnesses.

BackgroundHeatstroke is associated with exposure to high ambient temperature (AT) and relative humidity (RH), and an increased risk of organ damage or death. Previously proposed animal models of heatstroke disregard the impact of RH. Therefore, we aimed to establish and validate an animal model of heatstroke considering RH. To validate our model, we also examined the effect of hydration and investigated gene expression of cotransporter proteins in the intestinal membranes after heat exposure.MethodsMildly dehydrated adult male C57/BL6J mice were subjected to three AT conditions (37 °C, 41 °C, or 43 °C) at RH > 99% and monitored with WetBulb globe temperature (WBGT) for 1 h. The survival rate, body weight, core body temperature, blood parameters, and histologically confirmed tissue damage were evaluated to establish a mouse heatstroke model. Then, the mice received no treatment, water, or oral rehydration solution (ORS) before and after heat exposure; subsequent organ damage was compared using our model. Thereafter, we investigated cotransporter protein gene expressions in the intestinal membranes of mice that received no treatment, water, or ORS.ResultsThe survival rates of mice exposed to ATs of 37 °C, 41 °C, and 43 °C were 100%, 83.3%, and 0%, respectively. From this result, we excluded AT43. Mice in the AT 41 °C group appeared to be more dehydrated than those in the AT 37 °C group. WBGT in the AT 41 °C group was > 44 °C; core body temperature in this group reached 41.3 ± 0.08 °C during heat exposure and decreased to 34.0 ± 0.18 °C, returning to baseline after 8 h which showed a biphasic thermal dysregulation response. The AT 41 °C group presented with greater hepatic, renal, and musculoskeletal damage than did the other groups. The impact of ORS on recovery was greater than that of water or no treatment. The administration of ORS with heat exposure increased cotransporter gene expression in the intestines and reduced heatstroke-related damage.ConclusionsWe developed a novel mouse heatstroke model that considered AT and RH. We found that ORS administration improved inadequate circulation and reduced tissue injury by increasing cotransporter gene expression in the intestines.

Background: Accidental hypothermia (AH) has a low frequency, and the length of hospital stay in patients with AH remains poorly understood. The present study explored which factors were related to long-term hospitalization among patients with AH using Japan’s nationwide registry data.Methods: The data from the Hypothermia STUDY 2018, which included patients ≥ 18 years old with a body temperature ≤ 35°C, were obtained from a multicenter registry for AH conducted at 89 institutions throughout Japan, collected from December 1, 2018, to February 28, 2019. The patients were divided into a “short-stay patients” group (within 7 days) and “long-stay patients” group (more than 7 days). A logistic regression analysis after multiple imputation was performed to obtain odds ratios (ORs) for prolonged hospitalization with age, frailty, cause of hypothermia, mechanism underlying hypothermia, temperature, pH, potassium level, and disseminated intravascular coagulation (DIC) score as independent variables.Results: In total, 656 patients were included in the study, of which 362 were eligible for the analysis. The median length of hospital stay was 17 days. Of the 362 patients, 265 (73.2%) stayed in the hospital for more than 7 days. The factors associated with prolonged hospitalization were frailty (OR, 2.11; 95% confidence interval [CI], 1.09-4.10; p = 0.027), the occurrence of indoor (OR, 3.20; 95% CI, 1.58-6.46; p = 0.001), alcohol intoxication (OR, 0.17; 95% CI, 0.05-0.56; p = 0.004), pH (OR, 0.07; 95% CI, 0.01-0.76; p = 0.029), potassium level (OR, 1.36; 95% CI, 1.00-1.85; p = 0.048), and DIC score (OR, 1.54; 95% CI, 1.13-2.10; p = 0.006). Conclusions: Frailty, indoor situation, alcohol intoxication, pH, potassium level, and DIC score were factors contributing to prolonged hospitalization in patients with AH. These factors can be valuable for the early detection of AH requiring a prolonged hospital stay.

Purpose Heat stroke (HS) induces disseminated intravascular coagulation (DIC); however, the prognostic significance of DIC in patients with HS has not yet been fully assessed in large populations. The aim of this study was to examine the prognostic significance of DIC in patients with HS using a nationwide registry. Materials and methods Data regarding HS were obtained and analyzed from three prospective, observational, multicenter HS registries (HSRs): 2010, 2012, and 2014. Univariate and multivariate analyses were performed to identify independent predictors of hospital death. DIC was diagnosed according to the Japanese Association for Acute Medicine (JAAM) diagnostic criteria, with a total score ≥ 4 implying a DIC diagnosis. Results In total, 705 (median age, 68 years; 501 men) were included in this study. Hospital mortality was 7.1% (50 patients). Multiple regression analysis revealed that hospital mortality was significantly associated with presence of DIC (odds ratio [OR], 2.16; 95% confidence interval [CI], 1.09–4.27; p = 0.028). Mortality worsened as the DIC score increased, and increased remarkably to approximately 10% when the DIC score was 2. Conclusions Presence of DIC was an independent prognostic factor of hospital mortality in patients with HS. Hematological dysfunction represents potential target for specific therapies in HS.

Introduction Extracorporeal life support (ECLS) has been reported to be more effective than conventional cardiopulmonary resuscitation (CPR). In ECLS, a shorter time from arrival to implantation of extracorporeal membrane oxygenation (ECMO; door-to-ECMO) time was predicted to be associated with better survival rates. This study aimed to examine the impact of the physician-based emergency medical services (P-EMS) using a rapid response car (RRC) on door-to-ECMO time in patients with out-of-hospital cardiac arrest (OHCA). Methods In this retrospective cohort study, adult patients with OHCA who were admitted to a Japanese tertiary care hospital from April 2012 to December 2016 and underwent venoarterial ECMO were included. Patients were either transferred by emergency medical service (EMS only group) or RRC (RRC group). Primary outcome was door-to-ECMO time. Wilcoxon rank-sum test was used to compare the outcome between the two groups. Results A total of 34 patients were included in this study, and outcome data were available for all patients. The door-to-ECMO time was significantly shorter in the RRC group than in the EMS only group (median, 23 min vs. 36 min; P = 0.006). Additionally, the RRC was also associated with earlier successful intubation and intravenous adrenaline administration. Conclusion The physician-based RRC system was associated with a shorter door-to-ECMO time and successful advanced procedures in prehospital settings. Combination of the RRC system with ECLS may lead to better outcomes in patients with OHCA.

Aim Heat‐related illness is common, but its epidemiology and pathological mechanism remain unclear. The aim of this study was to report current clinical characteristics, prognostic factors, and outcomes of heat‐related illness in Japan. Methods We undertook a prospective multicenter observational study in Japan. Only hospitalized patients with heat‐related illness were enrolled from 1 July to 30 September 2017 and 1 July to 30 September 2018. Results A total of 763 patients were enrolled in the study. Median age was 68 years (interquartile range, 49–82 years) and median body temperature on admission was 38.2°C (interquartile range, 36.8–39.8°C). Non‐exertional cause was 56.9% and exertional cause was 40.0%. The hospital mortality was 4.6%. The median Japanese Association for Acute Medicine disseminated intravascular coagulation (JAAM DIC), Sequential Organ Failure Assessment (SOFA), and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores on admission were 1 (0–2), 4 (2–6), and 13 (8–22), respectively. To predict hospital mortality, areas under the receiver operating characteristic curves were 0.776 (JAAM DIC score), 0.825 (SOFA), and 0.878 (APACHE II). There were 632 cases defined as heatstroke by JAAM heat‐related illness criteria, 73 cases diagnosed as having DIC. A total of 16.6% patients had poor neurological outcome (modified Rankin Scale ≥ 4) at hospital discharge. In the multivariate analysis, Glasgow Coma Scale and platelets were independent predictors of mortality. Type of heatstroke, Glasgow Coma Scale, and platelets were independent predictors of poor neurological outcome. Body temperature was not associated with mortality or poor neurological outcome. Conclusions In this study, hospital mortality of heat‐related illness was, Receiver operating characteristic curves of the Acute Physiology and Chronic Health Evaluation II, Sequential Organ Failure Assessment, and Japanese Association for Acute Medicine disseminated intravascular coagulation scores for predicting hospital mortality in cases of heat‐related illness in Japan.

Background: This study aims to compare the Bouchama heatstroke (B-HS) and Japanese Association for Acute Medicine heatstroke (JAAM-HS) criteria with regard to the diagnosis and prediction of mortality and neurological status of heatstroke patients. Methods: This multicenter observational study recruited eligible patients from the emergency departments of 110 major hospitals in Japan from 1 July to 30 September, 2014. Results: A total of 317 patients (median age, 65 years, interquartile range, 39&ndash, 80 years) were included and divided into the B-HS, JAAM-HS, and non-HS groups, with each group consisting of 97, 302, and 15 patients, respectively. The JAAM-HS (1.0, 95% confidence interval [CI], 0.87&ndash, 1.0) and B-HS (0.29, 95% CI, 0.14&ndash, 0.49) criteria showed high and low sensitivity to mortality, respectively. Similarly, the JAAM-HS (1.0, 95% CI, 0.93&ndash, 1.0) and B-HS (0.35, 95% CI, 0.23&ndash, 0.49) criteria showed high and low sensitivity to poor neurological status, respectively. Meanwhile, the sequential organ failure assessment (SOFA) scores demonstrated good accuracy in predicting mortality among heat-related illness (HRI) patients. However, both JAAM-HS and B-HS criteria could not predict in-hospital mortality. The AUC of the SOFA score for mortality was 0.83 (day 3) among the HRI patients. The patients&rsquo, neurological status was difficult to predict using the JAAM-HS and B-HS criteria. Concurrently, the total bilirubin level could relatively predict the central nervous system function at discharge. Conclusions: The JAAM-HS criteria showed high sensitivity to mortality and could include all HRI patients who died. The JAAM-HS criterion was considered a useful tool for judgement of admission at ED. Further investigations are necessary to determine the accuracy of both B-HS and JAAM-HS criteria in predicting mortality and neurological status at discharge.

The Japanese Association for Acute Medicine Committee recently proposed a novel classification system for the severity of heat-related illnesses. The illnesses are simply classified into three stages based on symptoms and management or treatment. Stages I, II, and III broadly correspond to heat cramp and syncope, heat exhaustion, and heat stroke, respectively. Our objective was to examine whether this novel severity classification is useful in the diagnosis by healthcare professionals of patients with severe heat-related illness and organ failure. A nationwide surveillance study of heat-related illnesses was conducted between June 1 and September 30, 2012, at emergency departments in Japan. Among the 2130 patients who attended 102 emergency departments, the severity of their heat-related illness was recorded for 1799 patients, who were included in this study. In the patients with heat cramp and syncope or heat exhaustion (but not heat stroke), the blood test data (alanine aminotransferase, creatinine, blood urea nitrogen, and platelet counts) for those classified as stage III were significantly higher than those of patients classified as stage I or II. There were no deaths among the patients classified as stage I. This novel classification may avoid underestimating the severity of heat-related illness.

The Japanese Association for Acute Medicine Committee recently proposed a novel classification system for the severity of heat-related illnesses. The illnesses are simply classified into three stages based on symptoms and management or treatment. Stages I, II, and III broadly correspond to heat cramp and syncope, heat exhaustion, and heat stroke, respectively. Our objective was to examine whether this novel severity classification is useful in the diagnosis by healthcare professionals of patients with severe heat-related illness and organ failure. A nationwide surveillance study of heat-related illnesses was conducted between 1 June and 30 September 2012, at emergency departments in Japan. Among the 2130 patients who attended 102 emergency departments, the severity of their heat-related illness was recorded for 1799 patients, who were included in this study. In the patients with heat cramp and syncope or heat exhaustion (but not heat stroke), the blood test data (alanine aminotransferase, creatinine, blood urea nitrogen, and platelet counts) for those classified as Stage III were significantly higher than those of patients classified as Stage I or II. There were no deaths among the patients classified as Stage I. This novel classification may avoid underestimating the severity of heat-related illness.