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Abstract Rapid assessment of severity is crucial for timely intervention and improved patient outcomes in heatstroke (HS). However, existing biomarkers are limited in their accuracy and accessibility in ER settings. A prospective pilot study was conducted to assess urinary liver fatty acid-binding protein (L-FABP) levels using a point-of-care testing (POCT) upon HS. Severity was estimated using initial Sequential Organ Failure Assessment (SOFA) scores, and outcomes were measured using modified Rankin Scale (mRS) scores. In 78 severe HS patients, semi-quantitative L-FABP measurements were performed in ER and patients were divided as P-group (positive group, L-FABP ≧ 12.5 ng/mL on POCT) and N-group (negative group: L-FABP 100 ng/ml, P = 0.001). Additionally, patients in the POCT positive group had significantly worse outcomes at discharge compared to the negative group, although this difference diminished over time. The study demonstrates the feasibility and potential utility of POCT for initial L-FABP in estimating severity in HS patients. This rapid and accessible testing method may aid in early field triage and intervention, ultimately improving patient outcomes in the management of HS.

Abstract Background Factor Xa inhibitors are direct oral anticoagulants that are extremely useful in clinical applications, safe, and do not require dose adjustment. It is desirable to be able to monitor their effects in the event of hemorrhagic complications requiring neutralization. However, it is difficult to monitor their activity and neutralization using conventional coagulation tests. Case Presentation We report three patients taking factor Xa inhibitors who underwent rotational thromboelastography (ROTEM) monitoring before and after neutralization with andexanet alfa. All three patients had hemorrhagic complications that required neutralization of their factor Xa inhibitors using andexanet alfa. One ROTEM parameter, the EXTEM clotting time (EXTEM‐CT), was immediately shortened after andexanet alfa bolus administration, without subsequent extension of the EXTEM‐CT assessed 4 h after the bolus dose. Conclusion ROTEM parameters, particularly EXTEM‐CT, might be useful for monitoring neutralization of factor Xa inhibitors.

Therapeutic hypothermia for severe traumatic brain injury (TBI) has been repeatedly studied, but no past studies have assessed the detailed head computed tomography (CT) findings. We sought to investigate individual CT findings of severe TBI patients treated with targeted temperature management utilizing the head CT database obtained from the Brain Hypothermia study. Enrolled patients underwent either mild therapeutic hypothermia (32.0?C?34.0?C) or fever control (35.5?C?37.0?C). We assessed individual head CT images on arrival and after rewarming and investigated the correlations with outcomes. The initial CT data were available for 125 patients (hypothermia group?=?80, fever control group?=?45). Baseline characteristics and CT findings, such as hematoma thickness and midline shift, were similar in all aspects between the two groups. The favorable outcomes in the hypothermia and fever control groups were 38 (47.5%) and 24 (53.3%; p?=?0.53) for all 125 patients, respectively; 21 (46.7%) vs. 10 (38.5%; p?=?0.50) for 71 patients with acute subdural hematoma (SDH), respectively; and 12 (75.0%) vs. 4 (36.4%; p?=?0.045) in 27 young adults (?50 years) with acute SDH, respectively. There was a trend toward favorable outcomes for earlier time to reach 35.5?C (190 vs. 377?min, p?=?0.052) and surgery (155 vs. 180?min, p?=?0.096) in young patients with acute SDH. The second CT image revealed progression of the brain injury. This study demonstrated the potential benefits of early hypothermia in young patients with acute SDH, despite no difference in CT findings between the two groups. However, the small number of cases involved hindered the drawing of definitive conclusions. Future studies are warranted to validate the results.

Summary: Background: Inhaled molecular hydrogen gas (H2) has been shown to improve outcomes in animal models of cardiac arrest (CA). H2 inhalation is safe and feasible in patients after CA. We investigated whether inhaled H2 would improve outcomes after out-of-hospital CA (OHCA). Methods: HYBRID II is a prospective, multicentre, randomised, double-blind, placebo-controlled trial performed at 15 hospitals in Japan, between February 1, 2017, and September 30, 2021. Patients aged 20–80 years with coma following cardiogenic OHCA were randomly assigned (1:1) using blinded gas cylinders to receive supplementary oxygen with 2% H2 or oxygen (control) for 18 h. The primary outcome was the proportion of patients with a 90-day Cerebral Performance Category (CPC) of 1 or 2 assessed in a full-analysis set. Secondary outcomes included the 90-day score on a modified Rankin scale (mRS) and survival. HYBRID II was registered with the University Hospital Medical Information Network (registration number: UMIN000019820) and re-registered with the Japan Registry for Clinical Trials (registration number: jRCTs031180352). Findings: The trial was terminated prematurely because of the restrictions imposed on enrolment during the COVID-19 pandemic. Between February 1, 2017, and September 30, 2021, 429 patients were screened for eligibility, of whom 73 were randomly assigned to H2 (n = 39) or control (n = 34) groups. The primary outcome, i.e., a CPC of 1 or 2 at 90 days, was achieved in 22 (56%) and 13 (39%) patients in the H2 and control groups (relative risk compared with the control group, 0.72; 95% CI, 0.46–1.13; P = 0.15), respectively. Regarding the secondary outcomes, median mRS was 1 (IQR: 0–5) and 5 (1–6) in the H2 and control groups, respectively (P = 0.01). An mRS score of 0 was achieved in 18 (46%) and 7 (21%) patients in the H2 and control groups, respectively (P = 0.03). The 90-day survival rate was 85% (33/39) and 61% (20/33) in the H2 and control groups, respectively (P = 0.02). Interpretation: The increase in participants with good neurological outcomes following post-OHCA H2 inhalation in a selected population of patients was not statistically significant. However, the secondary outcomes suggest that H2 inhalation may increase 90-day survival without neurological deficits. Funding: Taiyo Nippon Sanso Corporation. Translation: For the Japanese translation of the abstract see Supplementary Materials section.

BackgroundThe purpose of this study was to examine whether the temperature difference between the jugular bulb and pulmonary artery (ΔTjb-pa) is associated with the neurological outcome of patients with severe traumatic brain injury (TBI).MethodsWe conducted a post hoc analysis of a multicenter randomized controlled trial of mild therapeutic hypothermia (TH, 32.0-34.0°C) or fever control (FC, 35.5-37.0°C) for the patients with severe TBI. ΔTjb-pa averaged every 12 h and the variation in ΔTjb-pa were compared between patients with favorable (n = 39) and unfavorable (n = 37) neurological outcomes. These values were also compared in the TH and FC subgroups.ResultsThe average ΔTjb-pa values in patients with favorable and unfavorable outcomes were 0.24 ± 0.23 and 0.06 ± 0.36°C, respectively (P < 0.001). ΔTjb-pa trended significantly higher in the favorable outcome patients than in the unfavorable outcome patients throughout the 120 h after onset of severe TBI (P < 0.001). The variation in ΔTjb-pa from 0 to 72 h was significantly lower in the favorable outcome patients than in the unfavorable outcome patients (0.8 ± 0.8 vs 1.8 ± 2.5°C, respectively, P = 0.013). From 72 to 120 h, there was no significant difference in the variation in ΔTjb-pa. Significant differences between patients with favorable and unfavorable outcomes in ΔTjb-pa and the variation in ΔTjb-pa were similar in the TH subgroup, but not evident in the FC subgroup.ConclusionsA reduction in ΔTjb-pa and greater variation in ΔTjb-pa were associated with an unfavorable outcome in patients with severe TBI, especially those treated with TH. When treating severe TBI patients, it is important to understand that there will be differences in temperature reflecting the brain environment and the systemic temperature, depending on the severity and outcome of TBI during TH.

Aim The study aimed to determine the current status of face mask use, deep body temperature measurement, and active cooling in patients suffering from heat stroke and heat exhaustion in Japan. Methods This was a prospective, observational, multicenter study using data from the Heatstroke STUDY 2020–2021, a nationwide periodical registry of heat stroke and heat exhaustion patients. Based on the Bouchama heatstroke criteria, we classified the patients into two groups: severe and mild‐to‐moderate. We compared the outcomes between the two groups and reclassified them into two subgroups according to the severity of the illness, deep body temperature measurements, and face mask use. Cramer's V was used to determine the effect sizes for a comparison between groups. Results Almost all patients in this study were categorized as having degree III based on the Japanese Association for Acute Medicine heatstroke criteria (JAAM‐HS). However, the severe group was significantly worse than the mild‐to‐moderate group in outcomes like in‐hospital death and modified Rankin Scale scores, when discharged. Heat strokes had significantly higher rates of active cooling and lower mortality rates than heat stroke‐like illnesses. Patients using face masks often use them during labor, sports, and other exertions, had less severe conditions, and were less likely to be young male individuals. Conclusions It is suggested that severe cases require a more detailed classification of degree III in the JAAM‐HS criteria, and not measuring deep body temperature could have been a factor in the nonperformance of active cooling and worse outcomes.

Abstract Aim To determine whether the rewarming rate is associated with neurological outcomes in patients with post–cardiac arrest syndrome treated with targeted temperature management (TTM) at 34°C. Methods We conducted a retrospective analysis of a nationwide cohort study of out‐of‐hospital cardiac arrest in Japan. Adult patients who experienced a return of spontaneous circulation and completed TTM at 34°C between June 2014 and December 2019 were divided equally into three groups (slow, moderate, and rapid) according to their rewarming rates from 34°C to 36°C. The rates of favorable neurological outcomes (Cerebral Performance Category of 1–2 after 30 days) were compared among the groups, and the adjusted odds ratios for a favorable neurological outcome were calculated for the groups. Results We analyzed 348, 357, and 358 patients in the slow, moderate, and rapid groups, respectively. The periods of rewarming from 34°C to 36°C were 41.9 ± 10.5, 22.4 ± 1.8, and 12.2 ± 3.6 h, respectively. The number of favorable neurological outcomes after 30 days was 121 (34.8%), 125 (35.0%), and 147 (41.1%), respectively, with no significant differences among the three groups (p = 0.145). Rapid rewarming was independently associated with a favorable neurological outcome compared with slow rewarming (adjusted odds ratio 1.57 [95% confidence interval 1.04–2.37]; p = 0.031). Conclusions Rapid rewarming after TTM at 34°C was associated with a more favorable neurological outcome than slow rewarming.

Abstract Aim To determine whether dispatcher‐provided cardiopulmonary resuscitation (CPR) instructions improve the outcomes of out‐of‐hospital cardiac arrest (OHCA). Methods Cases registered in the Japanese Association for Acute Medicine Out‐of‐Hospital Cardiac Arrest (JAAM‐OHCA) Registry between June 2014 and December 2019 were included. Cases in which the dispatcher provided CPR instructions to the bystander were included in the “Instructions” group”, and cases without CPR instructions were included in the “No Instructions” group. The primary outcome was the proportion of patients with a favorable neurological outcome, defined as a Glasgow–Pittsburgh cerebral performance category scale of 1 to 2 at 1 month after OHCA. Results Overall, 51,199 patients with OHCA were registered in the JAAM‐OHCA Registry during the study period. Of these, 33,745 were eligible for the study, with 16,509 in the Instructions group and 17,236 in the No Instructions group. The proportion of patients with a favorable neurological outcome at 1 month after OHCA was inferior in the Instructions group than in the No Instructions group (2.3% versus 3.0%, p

Abstract 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

Abstract The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members. As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.

Abstract 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.

Aim To assess heat stroke and heat exhaustion occurrence and response during the coronavirus disease 2019 pandemic in Japan. Methods 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. Results No significant differences were observed between 2019 and 2020. In both years, in‐hospital mortality rates just exceeded 8%. Individuals >65 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. Conclusion 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.

Aim To assess whether the outcomes of out‐of‐hospital cardiac arrest (OHCA) differ between patients treated at tertiary or secondary emergency medical facilities. Methods Data from the Japanese Association for Acute Medicine Out‐of‐Hospital Cardiac Arrest (JAAM‐OHCA) registry between June 2014 and December 2015 were analyzed and compared between patients treated at tertiary (tertiary group) and secondary (secondary group) emergency medical facilities. The primary outcome of this study was a favorable neurological outcome at 1 and 3 months after OHCA, defined as a Glasgow–Pittsburgh cerebral performance category of 1 or 2. Results Between June 2014 and December 2015, a total of 13,491 patients with OHCA were registered in the JAAM‐OHCA registry. Of these, 12,836 were eligible in the present analysis, with 11,583 in the tertiary group and 1,253 in the secondary group. The proportions of patients with favorable neurological outcomes in the tertiary group were significantly higher than those in the secondary group at 1 (4.7% versus 2.0%, P

BackgroundThe purpose of this study was to clarify the practical clinical treatment for acute carbon monoxide (CO) poisoning in Japan and to investigate the efficacy of hyperbaric oxygen (HBO2) therapy in preventing delayed neurological sequelae (DNS) in the acute phase of CO poisoning.MethodsWe conducted a multicenter, prospective, observational study of acute CO poisoning in Japan. Patients with acute CO poisoning were enrolled and their treatment details were recorded. The primary endpoint was the onset of DNS within 2 months of CO exposure. Factors associated with DNS were assessed with logistic regression analysis.ResultsA total of 311 patients from 57 institutions were registered and 255 were analyzed: 171 received HBO2 therapy (HBO2 group) and 84 did not (normobaric oxygen [NBO2] group). HBO2 therapy was performed zero, once, twice, or three times within the first 24 h in 1.8%, 55.9%, 30.9%, and 11.3% of the HBO2 group, respectively. The treatment pressure in the first HBO2 session was 2.8 ATA (47.9% of the HBO2 group), 2.0 ATA (41.8%), 2.5 ATA (7.9%), or another pressure (2.4%). The incidence of DNS was 13/171 (7.6%) in the HBO2 group and 3/84 (3.6%) in the NBO2 group (P = 0.212). The number of HBO2 sessions in the first 24 h was one of the factors associated with the incidence of DNS (odds ratio, 2.082; 95% confidence interval, 1.101-3.937; P = 0.024).ConclusionsThe practical clinical treatment for acute CO poisoning, including HBO2 therapy, varied among the institutions participating in Japan. HBO2 therapy with inconsistent protocols showed no advantage over NBO2 therapy in preventing DNS. Multiple HBO2 sessions was associated with the incidence of DNS.

Aim This study describes the clinical characteristics and outcomes as well as the prognostic factors of patients with accidental hypothermia (AH) using Japan’s nationwide registry data. Methods The Hypothermia study 2018 and 2019, which included patients aged 18 years or older with a body temperature of 35°C or less, was a multicenter registry conducted at 87 and 89 institutions throughout Japan, with data collected from December 2018 to February 2019 and December 2019 to February 2020, respectively. Results In total, 1363 patients were enrolled in the registry, of which 1194 were analyzed in this study. The median (interquartile range) age was 79 (68–87) years, and the median (interquartile range) body temperature at the emergency department was 30.8°C (28.4–33.6°C). Forty‐three percent of patients with AH had a mild condition, 35.2% moderate, and 21.9% severe. AH occurred in an indoor setting in 73.4% and was caused by acute medical illness in 49.3% of patients. A total of 101 (8.5%) patients suffered from cardiopulmonary arrest on arrival at the hospital. The overall 30‐day mortality rate was 24.5%, the median (interquartile range) intensive care unit stay was 4 (2–7) days, and the median (interquartile range) hospital stay was 13 (4–27) days. In the multivariable logistic analysis, the prognostic factors were age (≥75 years old), male, activities of daily living (needing total assistance), cause of AH (trauma, alcohol), Glasgow Coma Scale score, and potassium level (>5.5 mEq/L). Conclusion The mortality rate of AH was 24.5% in Japan. The prognostic factors developed in this study may be useful for the early prediction, prevention, and awareness of severe AH.

Abstract Background Serum neutrophil gelatinase-associated lipocalin (NGAL) is a well-known biomarker of acute kidney injury. Serum NGAL was recently proposed as a potential predictor of mortality in post cardiac arrest syndrome (PCAS) patients following out-of-hospital cardiac arrest (OHCA). However, the potential predictive value of NGAL for neurological outcomes is unknown. Therefore, we assessed the potential predictive value of NGAL for neurological outcomes after OHCA. We also compared its predictive value with that of neuron-specific enolase (NSE) as an established biomarker. Methods Blood samples were prospectively collected from 43 PCAS patients following OHCA. Serum NGAL was measured on days 1 and 2, and NSE was measured on day 2. These biomarkers were compared between patients with favourable (cerebral performance category [CPC] 1–2) and unfavourable (CPC 3–5) outcomes. Receiver operating characteristic (ROC) curve analysis was performed. Results Serum NGAL and NSE on day 2 (both P 20 mL/min/1.73 m2 (n = 38, 0.978 vs. 0.923) showed the potential of NGAL predictability. Conclusions Serum NGAL might predict the neurological outcomes of PCAS patients, and its predictive value was equivalent to that of NSE.

Aim A small spleen, which is occasionally found in patients with pneumococcal sepsis, may increase pneumococcal susceptibility because of splenic malfunction. However, a small spleen may also originate from severe disease. We carried out a retrospective study to evaluate the association between splenic volume and severe pneumococcal sepsis or disease severity. Methods We reviewed the medical records of 23 patients with severe pneumococcal sepsis treated at our institution between January 2004 and September 2015 (pneumococcal group) and 61 patients with severe non‐pneumococcal bacteremia treated between April 2011 and September 2015 (control group). Splenic volume measured by abdominal computed tomography on admission was compared between the two groups. Correlations between Acute Physiology and Chronic Health Evaluation (APACHE) II scores and splenic volume on admission and the change in splenic volume from the non‐septic state to admission were also determined. Results Splenic volume on admission was significantly smaller (P = 0.001) and a small spleen was more frequent (P < 0.001) in the pneumococcal group. The APACHE II score was negatively correlated with splenic volume on admission (r = −0.46, P < 0.001) and the change in splenic volume (r = −0.44, P = 0.004). Pneumococcal infection (odds ratio 13.1, 95% confidence interval 2.6–65.7; P = 0.002) and APACHE II score (odds ratio 1.2, 95% confidence interval 1.1–1.3; P = 0.002) were independently associated with small spleen. Conclusion Splenic volume decreased with increasing severity of severe sepsis. A small spleen was also associated with severe pneumococcal infection.

Case A 57‐year‐old woman was transferred to our emergency department by ambulance with cardiopulmonary arrest caused by massive genital bleeding. Cardiopulmonary resuscitation, including massive transfusion, was carried out and the return of spontaneous circulation was achieved. A giant uterine tumor was considered the source of the bleeding. Although hysterectomy was necessary to achieve definitive hemostasis, the patient was unable to tolerate the operation because of hemodynamic instability, acidosis, and coagulopathy. Therefore, we undertook vaginal gauze packing and uterine artery embolization to attain temporary hemostasis, which resulted in hemodynamic stabilization. Abdominal hysterectomy for definitive hemostasis was carried out 10 h after the embolization. Outcome The patient made a good post‐surgical recovery without any complications. Conclusion In treating hemorrhagic shock due to uterine leiomyoma, damage‐control resuscitation may be useful as a bridge prior to definitive hemostasis through hysterectomy.

Background. The aim of this study was to identify practice differences in the treatment of carbon monoxide (CO) poisoning with or without hyperbaric oxygen (HBO2) therapy in Japan. Materials and Methods. Using an online survey website (Google form), we created a questionnaire and invited interested institutions to join the COP-J Study, a prospective observational study of CO poisoning in Japan. Results. Forty-eight (63%) of 76 institutions replied to the questionnaire. Thirty-three institutions (69%) administered HBO2 therapy to patients with CO poisoning, and 15 institutions (31%) did not. Consciousness disturbance on arrival, exposure to CO for a long time, and elevation of arterial carboxyhemoglobin (CO-Hb) were the major indications for HBO2 therapy. The maximum therapeutic pressures were 2.0, 2.5, and 2.8 atmospheres absolute (ATA) at 19 (58%), 6 (18%), and 8 (24%) institutions, respectively. The number of HBO2 sessions on the first day was 1–3, and 1–7 sessions were administered on days 2–7. Seventeen (35%) institutions treated patients with delayed neurological sequelae (DNS) and 15 of them used HBO2 therapy for DNS. Conclusions. This survey indicates that HBO2 therapy for CO poisoning was varied in both the indications and practice regimens used in Japan.

Guanfacine hydrochloride extended-release (GXR) is used to treat attention deficit hyperactivity disorder. It is a selective α2A-adrenorecepor agonist that was reported to cause QT prolongation and hypotension in the event of overdosing. We report the case of a 17-year-old man who took 226 tablets of GXR 3 mg for attempted suicide. He was found complaining of dyspnea, and emergency medical services were called. When the patient was transferred to our hospital, his Glasgow coma scale was 12 (E4V3M5). He was agitated and hypoxemic. He was intubated for invasive mechanical ventilation under sedation. His chest X-ray and computed tomography scan showed pulmonary edema. Transthoracic echocardiography showed markedly reduced cardiac function. His serum guanfacine concentration peaked on day 3 after admission. His pulmonary edema improved quickly after a decrease in serum guanfacine concentration, but cardiac decompensation persisted for about 1 month. This case reveals that the decline in cardiac function after guanfacine intoxication is prolonged even after its serum concentration has decreased. [ABSTRACT FROM AUTHOR]