Heat stroke management during the COVID-19 pandemic: Recommendations from the experts in Japan (2nd edition).

Both coronavirus disease 2019 (COVID-19) and heat stroke have symptoms of fever or hyperthermia and the difficulty in distinguishing them could lead to a strain on emergency medical care. To mitigate the potential confusion that could arise from actions for preventing both COVID-19 spread and heat stroke, particularly in the context of record-breaking summer season temperatures, this work offers new knowledge and evidence that address concerns regarding indoor ventilation and indoor temperatures, mask wearing and heat stroke risk, and the isolation of older adults. Specifically, the current work is the second edition to the previously published guidance for handling heat stroke during the COVID-19 pandemic, prepared by the "Working group on heat stroke medical care during the COVID-19 epidemic," composed of members from four organizations in different medical and related fields. The group was established by the Japanese Association for Acute Medicine Heatstroke and Hypothermia Surveillance Committee. This second edition includes new knowledge, and conventional evidence gleaned from a primary selection of 60 articles from MEDLINE, one article from Cochrane, 13 articles from Ichushi, and a secondary/final selection of 56 articles. This work summarizes the contents that have been clarified in the prevention and treatment of infectious diseases and heat stroke to provide guidance for the prevention, diagnosis, and treatment of heat stroke during the COVID-19 pandemic.

Sepsis-Associated Delirium: A Narrative Review.

Delirium is characterized by an acutely altered mental status accompanied by reductions in cognitive function and attention. Delirium in septic patients, termed sepsis-associated delirium (SAD), differs in several specific aspects from the other types of delirium that are typically encountered in intensive care units. Since sepsis and delirium are both closely associated with increased morbidity and mortality, it is important to not only prevent but also promptly diagnose and treat SAD. We herein reviewed the etiology, pathogenesis, risk factors, prevention, diagnosis, treatment, and prognosis of SAD, including coronavirus disease 2019 (COVID-19)-related delirium. Delirium by itself not only worsens long-term prognosis, but it is also regarded as an important factor affecting the outcome of post-intensive care syndrome. In COVID-19 patients, the difficulties associated with adequately implementing the ABCDEF bundle (Assess, prevent, and manage pain; Both spontaneous awakening and breathing trials: Choice of analgesia and sedation; Delirium assess, prevent, and manage; Early mobility and exercise; Family engagement/empowerment) and the need for social isolation are issues that require the development of conventional care for SAD.

Use of two parallel oxygenators during veno-venous extracorporeal membrane oxygenation in a patient with severe obesity and COVID-19 pneumonia.

Background: Veno-Venous Extracorporeal Membrane Oxygenation (VV-ECMO) is one effective treatment for COVID-19 pneumonia, but controversy regarding VV-ECMO management in obese patients still exists. In this report, we described a case in which two oxygenators were used in parallel in a severely obese patient (Body mass index: 60 kg/m2, body surface area: 2.8 m2).Case: The case was of a 27-year-old man diagnosed with COVID-19 pneumonia and admitted to our hospital. VV-ECMO was required on the fifth day after admission due to gradually worsening respiratory conditions and partial pressure of arterial oxygen (PaO2)/FiO2 ratio of 77. Immediately after the initiation of VV-ECMO, post-oxygenator in circuit, PaO2 was low at 134 mmHg. Even though the VV-ECMO circuit was replaced on the same day, the PaO2 still was low at 261 mmHg. Thus, we decided to use two oxygenators in parallel, after which the PaO2 stabilized at 400-500 mmHg.Conclusions: In this case, VV-ECMO oxygenation could be stabilized by utilizing two oxygenators in parallel. Using two membrane oxygenators may be a treatment option in severely obese patients with respiratory failure.

Influence of the coronavirus disease 2019 (COVID-19) pandemic on the incidence of heat stroke and heat exhaustion in Japan: a nationwide observational study based on the Heatstroke STUDY 2019 (without COVID-19) and 2020 (with COVID-19).

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.

Dominance of the residential sector in Chinese black carbon emissions as identified from downwind atmospheric observations during the COVID-19 pandemic.

Emissions of black carbon (BC) particles from anthropogenic and natural sources contribute to climate change and human health impacts. Therefore, they need to be accurately quantified to develop an effective mitigation strategy. Although the spread of the emission flux estimates for China have recently narrowed under the constraints of atmospheric observations, consensus has not been reached regarding the dominant emission sector. Here, we quantified the contribution of the residential sector, as 64% (44-82%) in 2019, using the response of the observed atmospheric concentration in the outflowing air during Feb-Mar 2020, with the prevalence of the COVID-19 pandemic and restricted human activities over China. In detail, the BC emission fluxes, estimated after removing effects from meteorological variability, dropped only slightly (- 18%) during Feb-Mar 2020 from the levels in the previous year for selected air masses of Chinese origin, suggesting the contributions from the transport and industry sectors (36%) were smaller than the rest from the residential sector (64%). Carbon monoxide (CO) behaved differently, with larger emission reductions (- 35%) in the period Feb-Mar 2020, suggesting dominance of non-residential (i.e., transport and industry) sectors, which contributed 70% (48-100%) emission during 2019. The estimated BC/CO emission ratio for these sectors will help to further constrain bottom-up emission inventories. We comprehensively provide a clear scientific evidence supporting mitigation policies targeting reduction in residential BC emissions from China by demonstrating the economic feasibility using marginal abatement cost curves.

Variabilities in PM2.5 and Black Carbon Surface Concentrations Reproduced by Aerosol Optical Properties Estimated by In-Situ Data, Ground Based Remote Sensing and Modeling

Because of the increased temporal and spatial resolutions of the sensors onboard recently launched satellites, satellite-based surface aerosol concentration, which is usually estimated from the aerosol optical depth (AOD), is expected to become a strategic tool for air quality studies in the future. By further exploring the relationships of aerosol concentrations and their optical properties using ground observations, the accuracies of these products can be improved. Here, we analyzed collocated observations of surface mass concentrations of fine particulate matter (PM2.5) and black carbon (BC), as well as columnar aerosol optical properties from a sky radiometer and aerosol extinction profiles obtained by multi-axis differential optical absorption spectroscopy (MAX-DOAS), during the 2019–2020 period. We focused the analyses on a daily scale, emphasizing the role of the ultraviolet (UV) spectral region. Generally, the correlation between the AOD of the fine fraction (i.e., fAOD) and the PM2.5 surface concentration was moderately strong, regardless of considerations of boundary layer humidity and altitude. In contrast, the fAOD of the partial column below 1 km, which was obtained by combining sky radiometer and MAX-DOAS retrievals, better reproduced the variability of the PM2.5 and resulted in a linear relationship. In the same manner, we demonstrated that the absorption AOD of the fine fraction (fAAOD) of the partial column was related to the variability of the BC concentration. Analogous analyses based on aerosol products from the Modern-Era Retrospective analysis for Research and Applications, Version 2 (MERRA-2) confirmed these findings and highlighted the importance of the shape of the aerosol profile. Overall, our results indicated a remarkable consistency among the retrieved datasets, and between the datasets and MERRA-2 products. These results confirmed the well-known sensitivity to aerosol absorption in the UV spectral region;they also highlighted the efficacy of combined MAX-DOAS and sky radiometer observations.

Corticosteroid treatment for early acute respiratory distress syndrome: a systematic review and meta-analysis of randomized trials.

BACKGROUND: The effect of corticosteroid treatment on survival outcome in early acute respiratory distress syndrome (ARDS) is still debated. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to assess the efficacy of prolonged corticosteroid therapy in early ARDS. METHODS: We assessed the MEDLINE, Cochrane Central Register of Controlled Trials, and Web of Science databases from inception to August 1, 2020. We included RCTs that compared prolonged corticosteroid therapy with control treatment wherein the intervention was started within 72 h of ARDS diagnosis. Two investigators independently screened the citations and conducted the data extraction. The primary outcomes were all-cause 28- or 30-day mortality and 60-day mortality. Several endpoints such as ventilator-free days and adverse events were set as the secondary outcomes. DerSimonian-Laird random-effects models were used to report pooled odds ratios (ORs). RESULTS: Among the 4 RCTs included, all referred to the all-cause 28- or 30-day mortality. In the corticosteroid group, 108 of 385 patients (28.1%) died, while 139 of 357 (38.9%) died in the control group (pooled OR, 0.61; 95% confidence interval [CI], 0.44-0.85). Three RCTs mentioned the all-cause 60-day mortality. In the corticosteroid group, 78 of 300 patients (26.0%) died, while 101 of 265 (38.1%) died in the control group (pooled OR, 0.57; 95% CI, 0.40-0.83). For secondary outcomes, corticosteroid treatment versus control significantly prolonged the ventilator-free days (4 RCTs: mean difference, 3.74; 95% CI, 1.53-5.95) but caused hyperglycemia (3 RCTs: pooled OR, 1.52; 95% CI, 1.04-2.21). CONCLUSIONS: Prolonged corticosteroid treatment in early ARDS improved the survival outcomes. TRIAL REGISTRATION: PROSPERO, CRD42020195969.

Late i.v. steroid treatment for severe COVID-19-induced acute respiratory distress syndrome: a case report.

BACKGROUND: The efficacy of steroid treatment for coronavirus disease (COVID-19) is unknown. CASE PRESENTATION: A 67-year-old man was transported to our hospital due to impaired consciousness and respiratory failure. After admission, tracheal aspirate of the patient was harvested, and it tested positive for severe acute respiratory syndrome coronavirus 2 nucleic acid. He required veno-venous extracorporeal membrane oxygenation to sustain his oxygenation. However, his respiratory failure did not improve for 20 days. On day 20 of admission, we started to use i.v. steroid therapy. On day 23, lung opacity on the chest X-ray cleared and the patient's oxygen saturation improved significantly. We successfully removed extracorporeal membrane oxygenation on day 27. CONCLUSION: Our case report encourages more future trials to evaluate the therapeutic use of i.v. steroid in severe COVID-19-induced acute respiratory distress syndrome.