Apple-shaped obesity: A risky soil for cytokine-accelerated severity in COVID-19.

Obesity has been recognized as one of the most significant risk factors for the deterioration and mortality associated with COVID-19, but the significance of obesity itself differs among ethnicity. Multifactored analysis of our single institute-based retrospective cohort revealed that high visceral adipose tissue (VAT) burden, but not other obesity-associated markers, was related to accelerated inflammatory responses and the mortality of Japanese COVID-19 patients. To elucidate the mechanisms how VAT-dominant obesity induces severe inflammation after severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection, we infected two different strains of obese mice, C57BL/6JHamSlc-ob/ob (ob/ob), C57BLKS/J-db/db (db/db), genetically impaired in the leptin ligand and receptor, respectively, and control C57BL/6 mice with mouse-adapted SARS-CoV-2. Here, we revealed that VAT-dominant ob/ob mice were extremely more vulnerable to SARS-CoV-2 due to excessive inflammatory responses when compared to SAT-dominant db/db mice. In fact, SARS-CoV-2 genome and proteins were more abundant in the lungs of ob/ob mice, engulfed in macrophages, resulting in increased cytokine production including interleukin (IL)-6. Both an anti-IL-6 receptor antibody treatment and the prevention of obesity by leptin replenishment improved the survival of SARS-CoV-2-infected ob/ob mice by reducing the viral protein burden and excessive immune responses. Our results have proposed unique insights and clues on how obesity increases the risk of cytokine storm and death in patients with COVID-19. Moreover, earlier administration of antiinflammatory therapeutics including anti-IL-6R antibody to VAT-dominant patients might improve clinical outcome and stratification of the treatment for COVID-19, at least in Japanese patients.

Incidence and factor analysis for the heat-related illness on the Tokyo 2020 Olympic and Paralympic Games.

Introduction: Among the 43 venues of Tokyo 2020 Olympic Games (OG) and 33 venues of Paralympic Games (PG) were held, the heat island effect was highly expected to cause heat-related illnesses in the outdoor venues with maximum temperatures exceeding 35°C. However, the actual number of heat-related illness cases during the competition was lower than that was initially expected, and it was unclear under what conditions or environment-related heat illnesses occurred among athletes. Object: To clarify the cause and factors contributing to the occurrence of heat-related illness among athletes participating in the Tokyo 2020 Olympic and Paralympic Games. Method: This retrospective descriptive study included 15 820 athletes from 206 countries. From 21 July 2021 to 8 August 2021 for the Olympics, and from 24 August 2021 to 5 September 2021 for the Paralympics. The number of heat-related illness cases at each venue, the incidence rate for each event, gender, home continent, as well as the type of competition, environmental factors (such as venue, time, location and wet-bulb globe temperature (WBGT)), treatment factor and the type of competition were analysed. Results: More number of heat-related illnesses among athletes occurred at the OG (n=110, 76.3%) than at the PG (n=36, 23.7%). A total of 100 cases (100%) at the OG and 31 cases (86.1%) at the PG occurred at the outdoors venues. In the OG, a total of 50 cases (57.9%) occurred during the competition of marathon running and race walking at Sapporo Odori Park. Six of those, were diagnosed with exertional heat illness and treated with cold water immersion (CWI) at OG and one case at PG. Another 20 cases occurred in athletics (track and field) competitions at Tokyo National Olympic Stadium. In total, 10 cases (10.0%) were diagnosed with severe heat illness in the OG and 3 cases (8.3%) in the PG. Ten cases were transferred to outside medical facilities for further treatment, but no case has been hospitalised due to severe condition. In the factor analysis, venue zone, outdoor game, high WBGT (<28°C) and endurance sports have been found to have a higher risk of moderate and severe heat-related illness (p<0.05). The incidence rate and severity could be attenuated by proper heat-related illness treatment (CWI, ice towel, cold IV transfusion and oral hydration) reduced the severity of the illness, providing summer hot environment sports. Conclusion: The Tokyo 2020 Olympic and Paralympic summer games were held. Contrary to expectations, we calculated that about 1 in 100 Olympic athletes suffered heat-related illness. We believe this was due to the risk reduction of heat-related illness, such as adequate prevention and proper treatment. Our experience in avoiding heat-related illness will provide valuable data for future Olympic summer Games.

Cardiopulmonary Resuscitation: Let's Together Step into a New Era!

Although the out-of-hospital cardiac arrest (OHCA) survival rate has improved due to the spread of cardiopulmonary resuscitation (CPR) techniques and insights, OHCA remains a major public health issue worldwide [...].

Motivating factors for frontline healthcare workers during the COVID-19 pandemic: A survey in Japan.

Healthcare workers (HCWs), who are at the frontline of the COVID-19 pandemic, treated COVID-19 patients under many types of stress for over a year. As an external motivating factor, incentives could be important for HCWs dealing with COVID-19. However, there has been no research regarding the change in the consciousness of HCWs during the unrelenting waves of COVID-19. Therefore, we conducted a survey of HCWs during different waves of COVID-19 (the second and fourth waves in Japan). An open web-based survey was conducted among HCWs who wore PPE while treating COVID-19 patients. The first survey of HCWs in Japan was conducted from August 27 to September 9, 2020, while the second survey was conducted from April 7 to May 10, 2021, during the second and fourth waves, respectively. The first and second surveys had 157 and 125 participants, respectively. There were no significant differences in the characteristics of the participants in the first and second survey groups regarding the types of occupation, age, sex, or full-time status. The percentage of HCWs who required financial incentives to maintain motivation remained high (88.5% vs. 82.7%). In addition, most frontline HCWs hope for regular SARS-CoV-2 PCR testing, which will be provided free of charge, as a necessary incentive. External motivating factors, such as financial and other incentives, were important to maintain the motivation of HCWs during the second and fourth waves of the COVID-19 pandemic in Japan. Supplementary Information: The online version contains supplementary material available at 10.1007/s12144-022-04177-6.

Lots of luck on thin ice from Tokyo to Paris: Following the track of the preparedness and results of Emergency Medical Services and Disaster Medical Response during 2020 Tokyo Olympic and Paralympic Games from the Perspective of Academic Consortium (AC2020) of Japan and Medical Advisory Board of Tokyo Metropolitan Government

Summary Introduction The 2020 Tokyo Olympic and Paralympic Games (2020 Tokyo Olympics) was held in Japan during the pandemic of new coronavirus infection (COVID-19) in 2021. Preparedness In 2016, the Academic Consortium consisting of 29 major medical associations (AC2020) was launched and undertook medical risk assessment, issuing statements, and disseminating manuals/guidelines, training materials through its website. Administratively, Tokyo Organizing Committee of the Olympic and Paralympic Games (TOC) was responsible for preparations inside the venue, while Tokyo Metropolitan Government (TMG) was responsible for preparations on the last mile and around the venue. In response to the AC2020 recommendation, the TOC and TMG has set up the subcommittee for reviewing emergency and disaster medical systems for the games. Finally, the 2020 Tokyo Olympics gave up accepting spectators from abroad and limited domestic spectators. The multi-organizational training was not systematically performed until just prior to the event due to the delay in deciding on the form of this big event. Results A total of 779,820 people participated during the entire period. The 316 patients were seen at hospitals including 53 COVID- 19 cases, and the patient presentation rate (PPR) was 2.4/1000. The COVID-19 cases in Japan increased as the games approached, and a major wave peak of the epidemic was observed during the games. Conclusion If MCI had occurred during the games, the current medical care system would not have been able to cope with such situation. We were walking on thin ice, but fortunately, we didn’t step out and drown in the water. Résumé Introduction Les Jeux Olympiques et Paralympiques de Tokyo 2020 (Jeux Olympiques de Tokyo 2020) ont eu lieu au Japon pendant la pandémie COVID-19 en 2021. Préparation En 2016, le Consortium Académique composé de 29 grandes associations médicales (AC2020) a été lancé et a entrepris une évaluation des risques médicaux, publié des mises aux points et diffusé des manuels/directives, du matériel de formation via son site Web. Sur le plan administratif, le comité d’organisation des Jeux olympiques et paralympiques de Tokyo (TOC) était responsable des préparatifs à l’intérieur du site, tandis que le gouvernement métropolitain de Tokyo (TMG) était responsable des préparatifs sur le dernier kilomètre et autour du site. En réponse à la recommandation AC2020, le COT et le TMG ont mis en place le sous-comité chargé d’examiner les dispositifs prévisionnels de secours pour les urgences et en cas de catastrophe pour les jeux. Enfin, les Jeux Olympiques de Tokyo 2020 ont renoncé à recevoir des spectateurs étrangers et ont limité les spectateurs nationaux. La formation multi-organisationnelle n’a été systématiquement effectuée que juste avant l’événement en raison du retard dans la décision sur la forme de ce grand événement. Résultats Au total, 779820 personnes ont participé pendant toute la période. Les 316 patients ont été vus dans les hôpitaux dont 53 cas de COVID-19, et le taux de présentation des patients (PPR) était de 2,4/1000. Les cas de COVID-19 au Japon ont augmenté à l’approche des jeux, et un pic de vague majeur de l’épidémie a été observé pendant les jeux. Conclusion Si un afflux de victimes s’était produit pendant les jeux, le système de soins médicaux actuel n’aurait pas été en mesure de faire face à une telle situation. Nous marchions sur de la glace mince, mais heureusement, nous n’avons pas dérapé et ne nous sommes pas noyés dans l’eau.

Association of SARS-CoV-2 RNA Copy Number with the COVID-19 Mortality Rate and Its Effect on the Predictive Performance of Mortality in Severe Cases.

Factors associated with mortality are important in the treatment of coronavirus disease 2019 (COVID-19). Polymerase chain reaction (PCR) is the gold standard for diagnosing COVID-19, which reflects the viral load in the upper respiratory tract. In total, 523 patients were enrolled in this study; of them, 441 and 75 patients underwent PCR testing of nasopharyngeal swabs and sputum samples, respectively, within 20 days from onset of COVID-19. We investigated the association between RNA copy number and the COVID-19 severity and mortality rate and its effect on the predictive performance for severity and mortality. RNA copy numbers in nasopharyngeal swabs were higher in the non-survivor group than in the survivor group. Multivariate logistic regression analysis identified that the high RNA copy number (≥9 log10 /swab) in nasopharyngeal swabs was a factor associated with mortality (odds ratio, 4.50; 95% confidence interval, 1.510-13.100; P = 0.008). Furthermore, adding RNA copy number (≥9 log10 /swab) in severe cases, adjusted by duration from onset to PCR, improved mortality predictive performance based on known factors. The RNA copy number is a factor associated with the mortality of patients with COVID-19 and can improve the predictive performance of mortality in severe cases.

Hour-1 bundle adherence was associated with reduction of in-hospital mortality among patients with sepsis in Japan.

BACKGROUND: The updated Surviving Sepsis Campaign guidelines recommend a 1-hour window for completion of a sepsis care bundle; however, the effectiveness of the hour-1 bundle has not been fully evaluated. The present study aimed to evaluate the impact of hour-1 bundle completion on clinical outcomes in sepsis patients. METHODS: This was a multicenter, prospective, observational study conducted in 17 intensive care units in tertiary hospitals in Japan. We included all adult patients who were diagnosed as having sepsis by Sepsis-3 and admitted to intensive care units from July 2019 to August 2020. Impacts of hour-1 bundle adherence and delay of adherence on risk-adjusted in-hospital mortality were estimated by multivariable logistic regression analyses. RESULTS: The final study cohort included 178 patients with sepsis. Among them, 89 received bundle-adherent care. Completion rates of each component (measure lactate level, obtain blood cultures, administer broad-spectrum antibiotics, administer crystalloid, apply vasopressors) within 1 hour were 98.9%, 86.2%, 51.1%, 94.9%, and 69.1%, respectively. Completion rate of all components within 1 hour was 50%. In-hospital mortality was 18.0% in the patients with and 30.3% in the patients without bundle-adherent care (p = 0.054). The adjusted odds ratio of non-bundle-adherent versus bundle-adherent care for in-hospital mortality was 2.32 (95% CI 1.09-4.95) using propensity scoring. Non-adherence to obtaining blood cultures and administering broad-spectrum antibiotics within 1 hour was related to in-hospital mortality (2.65 [95% CI 1.25-5.62] and 4.81 [95% CI 1.38-16.72], respectively). The adjusted odds ratio for 1-hour delay in achieving hour-1 bundle components for in-hospital mortality was 1.28 (95% CI 1.04-1.57) by logistic regression analysis. CONCLUSION: Completion of the hour-1 bundle was associated with lower in-hospital mortality. Obtaining blood cultures and administering antibiotics within 1 hour may have been the components most contributing to decreased in-hospital mortality.

Therapeutic anticoagulation using heparin in early phase severe coronavirus disease 2019: A retrospective study.

BACKGROUND: Although several reports recommend the use of systemic anticoagulation therapy in patients with severe coronavirus disease 2019 (COVID-19) pneumonia, appropriate target population and timing of administration are unknown. We assessed association between therapeutic anticoagulation administration with unfractionated heparin and outcomes in patients with severe COVID-19 pneumonia, assuming that anticoagulant administration effects are influenced by therapy timing. METHODS: This retrospective observational study included severe COVID-19 patients requiring mechanical ventilation in a tertiary emergency critical care hospital intensive care unit (ICU) in Japan from May 1, 2020 to September 30, 2021. All included patients were divided into early and late-phase administration groups based on therapeutic anticoagulant administration timing (≤5 and >5 days, respectively, after commencing oxygen therapy). Primary outcomes (in-hospital mortality and adverse events related to anticoagulation therapy) and secondary outcomes [veno-venous extracorporeal membrane oxygenation (ECMO), ventilator-free days (VFD), and ICU-free days] were compared between groups using univariate and multivariate models. RESULTS: Of 198 included patients 104 (52.5%) and 94 (47.5%) were in early-phase and late-phase administration groups, respectively. Although background characteristics were similar between the groups, the early-phase administration group had a significantly lower in-hospital mortality rate (3.8% vs. 27.7%; p < 0.001), lower adverse event rates (1.9% vs. 12.8%; p < 0.001), significantly longer VFD and ICU-free days, and lower ECMO rates, than the late-phase administration group, in the multivariate model. CONCLUSIONS: Late administration of therapeutic-dose anticoagulation in patients with severe COVID-19 pneumonia was significantly associated with worse outcomes than early administration.

Arterial and Venous Thrombosis Complicated in COVID-19: A Retrospective Single Center Analysis in Japan.

Background: Thrombosis is a characteristic complication in coronavirus disease 2019 (COVID-19). Since coagulopathy has been observed over the entire clinical course, thrombosis might be a clue to understanding the specific pathology in COVID-19. Currently, there is limited epidemiological data of COVID-19-associated thrombosis in the Japanese population and none regarding variant strains of SARS-CoV-2. Here, we elucidate the risk factors and the pattern of thrombosis in COVID-19 patients. Methods: The patients consecutively admitted to Tokyo Medical and Dental University Hospital with COVID-19 were retrospectively analyzed. SARS-CoV-2 variants of concern/interest (VOC/VOI) carrying the spike protein mutants E484K, N501Y, or L452R were identified by PCR-based analysis. All thrombotic events were diagnosed by clinical symptoms, ultrasonography, and/or radiological tests. Results: Among the 516 patients, 32 patients experienced 42 thromboembolic events. Advanced age, severe respiratory conditions, and several abnormal laboratory markers were associated with the development of thrombosis. While thrombotic events occurred in 13% of the patients with a severe respiratory condition, those events still occurred in 2.5% of the patients who did not require oxygen therapy. Elevated D-dimer and ferritin levels on admission were independent risk factors of thrombosis (adjusted odds ratio 9.39 and 3.11, 95% confidence interval 2.08-42.3, and 1.06-9.17, respectively). Of the thrombotic events, 22 were venous, whereas 20 were arterial. While patients with thrombosis received anticoagulation and antiinflammatory therapies with a higher proportion, the mortality rate, organ dysfunctions, and bleeding complications in these patients were higher than those without thrombosis. The incidence of thrombosis in COVID-19 became less frequent over time, such as during the replacement of the earlier strains of SARS-CoV-2 by VOC/VOI and during increased use of anticoagulatory therapeutics. Conclusion: This study elucidated that elevated D-dimer and ferritin levels are useful biomarkers of thrombosis in COVID-19 patients. The comparable incidence of arterial thrombosis with venous thrombosis and the development of thrombosis in less severe patients required further considerations for the management of Japanese patients with COVID-19. Further studies would be required to identify high-risk populations and establish appropriate interventions for thrombotic complications in COVID-19.

Colon perforation as a complication of COVID-19: a case report.

BACKGROUND: Coagulopathy induced by COVID-19 has received much attention. Arterial and venous thrombosis of multiple organs due to COVID-19-related coagulopathy is associated with a poor outcome. CASE PRESENTATION: A 67-year-female was transferred to our hospital in need of intensive care for severe COVID-19 pneumonia. On day 7 after admission, despite the treatments, her respiratory and hemodynamic status deteriorated. Computed tomography revealed massive ascites and free air as well as wall defects of the transverse colon. An emergency laparotomy was undertaken in the intensive-care unit, and 17 cm of the transverse colon was resected. Histopathological findings revealed two perforation sites of 25 and 7 mm in diameter, necrosis of the intestinal mucosa around the perforation sites, and the microcirculatory thrombosis in the mesentery vessels which was suspected of having been induced by COVID-19-related coagulopathy. CONCLUSIONS: The case highlights the risk of intestinal ischemia and perforation induced by COVID-19 coagulopathy. Physicians treating COVID-19 should recognize the risk and evaluate patients carefully.

Anticoagulation therapy using unfractionated heparin at a therapeutic dose for coronavirus disease 2019 patients with severe pneumonia: a retrospective historical control study.

AIM: Patients with severe coronavirus disease 2019 (COVID-19) pneumonia often have complications of coagulopathy and thrombotic phenomena, which lead to high mortality. Whether administering systematic anticoagulant therapy is beneficial remains unclear. We report our experience using systemic anticoagulation with unfractionated heparin to treat severe COVID-19. METHODS: We conducted a retrospective historical control study of severe COVID-19 patients requiring mechanical ventilation who received prophylactic-dose anticoagulation (April 1-May 25) or therapeutic-dose anticoagulation (May 26-August 31) in the intensive care unit (ICU) of a tertiary emergency critical care medical center in Japan. The primary endpoints were in-hospital mortality and anticoagulation therapy-related adverse events. The secondary endpoints included thromboembolic events, administration of venovenous extracorporeal membrane oxygenation (ECMO), ventilator-free days (VFDs), ICU-free days, and the development of multiple organ dysfunction syndrome. RESULTS: A total of 29 and 33 patients were in the prophylactic-dose and therapeutic-dose groups, respectively. Background characteristics between the groups were not significantly different, although the therapeutic-dose group had a significantly lower in-hospital mortality rate [5 (17.2%) patients versus 0 (0.0%) patients; P = 0.033] and longer ICU-free days (median [interquartile range]: 15 days [13-18] versus 5 days [0-13]; P = 0.008). Hemorrhagic-events did not occur during the study period. Compared with the prophylactic-dose group, the therapeutic-dose group tended to have longer VFDs, was not treated with ECMO, and did not experience thromboembolic events and multiple organ dysfunction syndrome; however, the difference was not statistically significant. CONCLUSIONS: Therapeutic-dose anticoagulation may be beneficial for patients with severe COVID-19 pneumonia requiring mechanical ventilation.

An Experience of Multiple Hematomas in a Coronavirus Disease-19 Patient Administered with ART-123 and Heparin.

BACKGROUND: Anticoagulant therapy for patients with severe coronavirus disease (COVID-19) pneumonia is considered to improve the hypercoagulable and inflammatory state. However, bleeding complications should also be considered. CASE PRESENTATION: A 77-year-old man with a history of falls was diagnosed with COVID-19. Owing to his severe condition, he was intubated and transferred to our hospital for intensive care. Favipiravir, tocilizumab, unfractionated heparin, and ART-123 were administered to treat COVID-19 and manage the antithrombotic prophylaxis for paroxysmal atrial fibrillation (Af). On the 6th day after admission, a hematoma was noted on the left chest wall. Computed tomography (CT) revealed multiple hematomas, including hematomas on his chest wall and obturatorius internus muscle. Emergency angiography transcatheter embolization (TAE) was performed. The patient was transferred to another hospital 23 days after TAE, without complications. CONCLUSION: Our findings show that anticoagulation therapy and a history of falls induced multiple hematomas in a COVID-19 patient and that the condition was managed with TAE. When anticoagulants are considered in the management of Af and COVID-19 associated coagulopathy, it is necessary to closely monitor potential bleeding complications.

Efficacy of multidisciplinary team approach with extracorporeal membrane oxygenation for COVID-19 in a low volume ECMO center.

Veno-venous extracorporeal membrane oxygenation (VV ECMO) is an effective and proven adjunct support for various severe respiratory failures requiring invasive mechanical ventilation and cardiovascular support. In response to the rapidly increasing number of COVID-19 patients in Japan, we launched an ECMO support team comprised of multidisciplinary experts including physicians, nurses, perfusionists, and bioethicists in preparation for the threat of a pandemic. From April 2 to July 15, 2020, Tokyo Medical and Dental University hospital treated 104 PCR confirmed COVID-19 patients. Among those, 34 patients were admitted to intensive care unit (ICU) and 5 patients required VV ECMO. All management related to ECMO was decided by the ECMO support team in addition to participation of the ECMO support team in daily multidisciplinary rounds in the ICU. Median age was 54 years old. Duration from onset to mechanical ventilation (MV) and MV to ECMO were 8 and 7 days, respectively. Four patients (80%) were successfully weaned off from ECMO. One patient died after 81 days of ECMO run. Four patients were discharged and recovered to their prehospital quality of life without major disability. We achieved a high survival rate using ECMO in our low volume ECMO institution during the COVID-19 pandemic. Multidisciplinary decision-making and a team approach for the unclear pathology with an emerging infectious disease was effective and contributed to the survival rate.

Predictors associated with clinical improvement of SARS-CoV-2 pneumonia.

BACKGROUND: There are few agents that have been proven effective for COVID-19. Predicting clinical improvement as well as mortality or severity is very important. OBJECTIVES: This study aimed to investigate the factors associated with the clinical improvement of COVID-19. METHODS: Overall, 74 patients receiving treatment for COVID-19 at Tokyo Medical and Dental University Hospital from April 6th to May 15th, 2020 were included in this study. Clinical improvement was evaluated, which defined as the decline of two levels on a six-point ordinal scale of clinical status or discharge alive from the hospital within 28 days after admission. The clinical courses were particularly investigated and the factors related to time to clinical improvement were analyzed with the log-rank test and the Cox proportional hazard model. RESULTS: Forty-nine patients required oxygen support during hospitalization, 22 patients required invasive mechanical ventilation, and 5 patients required extracorporeal membrane oxygenation. A total of 83% of cases reached clinical improvement. Longer period of time from onset to admission (≥10 days) (HR, 1.057; 95% CI, 1.002-1.114), no hypertension (HR, 2.077; 95% CI, 1.006-4.287), and low D-dimer levels (<1 µg/ml) (HR, 2.372; 95% CI, 1.229-4.576) were confirmed to be significant predictive factors for time to clinical improvement. Furthermore, a lower SARS-CoV-2 RNA copy number was also a predictive factor for clinical improvement. CONCLUSIONS: Several predictors for the clinical improvement of COVID-19 pneumonia were identified. These results may be important for the management of COVID-19 pneumonia.

Medicine at mass gatherings: current progress of preparedness of emergency medical services and disaster medical response during 2020 Tokyo Olympic and Paralympic Games from the perspective of the Academic Consortium (AC2020).

Mass gatherings are events characterized by "the concentration of people at a specific location for a specific purpose over a set period of time that have the potential to strain the planning and response resources of the host country or community." Previous reports showed that, as a result of the concentration of people in the limited area, injury and illness occurred due to several factors. The response plan should aim to provide timely medical care to the patients and to reduce the burden on emergency hospitals, and to maintain a daily emergency medical services system for residents of the local area. Although a mass gathering event will place a significant burden on the local health-care system, it can provide the opportunity for long-term benefits of public health-care and improvement of daily medical service systems after the end of the event. The next Olympic and Paralympic Games will be held in Tokyo, during which mass gatherings will occur on a daily basis in the context of the coronavirus disease (COVID-19) epidemic. The Academic Consortium on Emergency Medical Services and Disaster Medical Response Plan during the Tokyo Olympic and Paralympic Games in 2020 (AC2020) was launched 2016, consisting of 28 academic societies in Japan, it has released statements based on assessments of medical risk and publishing guidelines and manuals on its website. This paper outlines the issues and countermeasures for emergency and disaster medical care related to the holding of this big event, focusing on the activities of the academic consortium.

A successful case of extracorporeal membrane oxygenation treatment for intractable pneumothorax in a patient with COVID-19.

BACKGROUND: Some patients with coronavirus disease 2019 (COVID-19) develop pneumothorax. Tube thoracotomy and bulla resection could generate aerosols and cause virus transmission; the optimal treatment strategy remains unclear. CASE PRESENTATION: A 57-year-old male was transferred as a severe COVID-19 pneumonia case. On the 16th day after admission, the patient's respiratory condition deteriorated, and the chest X-ray revealed the presence of severe right-sided pneumothorax. A chest drain was immediately inserted; however, a significant air leak continued, and severe ventilator settings were required. Thus, veno-venous extracorporeal membrane oxygenation (VV-ECMO) treatment was initiated to allow the lungs to rest. After 10 days of lung-protective ventilation, the patient was weaned from ECMO and the chest drain was removed on the following day with no major comorbidities. CONCLUSION: The combination of ECMO with lung rest strategy could be a treatment option for intractable pneumothorax with COVID-19 to avoid unnecessary surgical procedures and aerosol generation.

Severe COVID-19 Pneumonia in a 30-Year-Old Woman in the 36th Week of Pregnancy Treated with Postpartum Extracorporeal Membrane Oxygenation.

BACKGROUND There are few reports of coronavirus disease 2019 (COVID-19) in pregnant women. Although coagulation dysfunction was reported to affect the severity of COVID-19, the association between pregnancy, which is usually accompanied by changes in coagulation function, and the worsening of COVID-19 is unknown. We present a case of a 30-year-old woman in the 36th week of pregnancy who was diagnosed with severe COVID-19 pneumonia and required postpartum extracorporeal membrane oxygenation (ECMO) therapy. CASE REPORT A 30-year-old, 36-weeks pregnant woman presented to our hospital and was diagnosed with severe COVID-19 pneumonia soon after she had undergone a cesarean section. Her respiratory failure could not be managed by conventional therapeutic approaches. Therefore, ECMO was administered on day 7. Controlling coagulation function to maintain ECMO therapy was challenging. Nafamostat mesylate and cryoprecipitate were administered to treat the hypercoagulative status and severe hypofibrinogenemia, respectively. Since coagulopathy and her respiratory state improved, the ECMO therapy was terminated on day 15. CONCLUSIONS We report a case of severe COVID-19 pneumonia in a pregnant woman urgently treated with ECMO in the postpartum period. Thus, this case highlights the importance of close monitoring and appropriate medical care for pregnant women with severe COVID-19 pneumonia.

MuLBSTA score is a useful tool for predicting COVID-19 disease behavior.

BACKGROUND: The prediction of COVID-19 disease behavior in the early phase of infection is challenging but urgently needed. MuLBSTA score is a scoring system that predicts the mortality of viral pneumonia induced by a variety of viruses, including coronavirus, but the scoring system has not been verified in novel coronavirus pneumonia. The aim of this study was to validate this scoring system for estimating the risk of disease worsening in patients with COVID-19. METHODS: This study included the patients who were treated between April 1 st and March 13 th , 2020. The patients were classified into mild, moderate, and severe groups according to the extent of respiratory failure. MuLBSTA score was applied to estimate the risk of disease worsening in each severity group and we validated the utility of the scoring system. RESULTS: A total of 72 patients were analyzed. Among the 46 patients with mild disease, 17 showed disease progression to moderate or severe disease after admission. The model showed a sensitivity of 100% and a specificity of only 34.5% with a cut-off value of 5 points. Among the 55 patients with mild or moderate disease, 6 deteriorated to severe disease, and the model showed a sensitivity of 83.3% and a specificity of 71.4% with a cut-off value of 11 points. CONCLUSIONS: This study showed that MuLBSTA score is a potentially useful tool for predicting COVID-19 disease behavior. This scoring system may be used as one of the criteria to identify high-risk patients worsening to life-threatening status.