Usefulness of the hybrid technique of interventional radiology and endoscopic treatment for intestinal bleeding after pancreaticoduodenectomy: a case report.

Introduction and importance: In endovascular treatment of ruptured pseudoaneurysm after pancreaticoduodenectomy (PD) with gastrointestinal bleeding, treatment for vasospasm of the culprit vessel from haemorrhagic shock and subsequent reperfusion has not been determined before. Case presentation: The authors hereby present you with a case of a 59-year-old man with unknown operative method upon arrival at the Emergecy room and who had hematemesis and collapse 6 months post-PD surgery. Clinical discussion: An initial contrast-enhanced computed tomography (CT) revealed no obvious source of bleeding, so an upper gastrointestinal endoscope was performed. Rebleeding occurred during the examination, and interventional radiology was performed because haemostasis was difficult. Coil embolization was performed for leakage of contrast material from the gastroduodenal artery stump into the gastrointestinal tract. However, because the embolization was uncertain due to vasospasm of the common hepatic artery, endoscopic clipping of the perforation site was also performed to prevent rebleeding due to reperfusion after improvement of vasospasm. A CT scan 5 days later showed reperfusion of the coil-implanted vessel. No rebleeding or hepatic infarction occurred postoperatively. Conclusion: In this case, the haemostasis by coil embolization was uncertain due to the presence of vasospasm, and clipping was used in combination with the procedure to prevent rebleeding.

Intravenous lipid emulsion for local anaesthetic systemic toxicity in pregnant women: a scoping review.

BACKGROUND: Local anaesthetic systemic toxicity (LAST) is a rare but life-threatening complication that can occur after local anaesthetic administration. Various clinical guidelines recommend an intravenous lipid emulsion as a treatment for local anaesthetic-induced cardiac arrest. However, its therapeutic application in pregnant patients has not yet been established. This scoping review aims to systematically identify and map the evidence on the efficacy and safety of intravenous lipid emulsion for treating LAST during pregnancy. METHOD: We searched electronic databases (Medline, Embase and Cochrane Central Register Controlled Trials) and a clinical registry (lipidrescue.org) from inception to Sep 30, 2022. No restriction was placed on the year of publication or the language. We included any study design containing primary data on obstetric patients with signs and symptoms of LAST. RESULTS: After eliminating duplicates, we screened 8,370 titles and abstracts, retrieving 41 full-text articles. We identified 22 women who developed LAST during pregnancy and childbirth, all presented as case reports or series. The most frequent causes of LAST were drug overdose and intravascular migration of the epidural catheter followed by wrong-route drug errors (i.e. intravenous anaesthetic administration). Of the 15 women who received lipid emulsions, all survived and none sustained lasting neurological or cardiovascular damage related to LAST. No adverse events or side effects following intravenous lipid emulsion administration were reported in mothers or neonates. Five of the seven women who did not receive lipid emulsions survived; however, the other two died. CONCLUSION: Studies on the efficacy and safety of lipids in pregnancy are scarce. Further studies with appropriate comparison groups are needed to provide more robust evidence. It will also be necessary to accumulate data-including adverse events-to enable clinicians to conduct risk-benefit analyses of lipids and to facilitate evidence-based decision-making for clinical practice.

Regulatory Role of GgaR (YegW) for Glycogen Accumulation in Escherichia coli K-12.

Glycogen, the stored form of glucose, accumulates upon growth arrest in the presence of an excess carbon source in Escherichia coli and other bacteria. Chromatin immunoprecipitation screening for the binding site of a functionally unknown GntR family transcription factor, YegW, revealed that the yegTUV operon was a single target of the E. coli genome. Although none of the genes in the yegTUV operon have a clear function, a previous study suggested their involvement in the production of ADP-glucose (ADPG), a glycogen precursor. Various validation through in vivo and in vitro experiments showed that YegW is a single-target transcription factor that acts as a repressor of yegTUV, with an intracellular concentration of consistently approximately 10 molecules, and senses ADPG as an effector. Further analysis revealed that YegW repressed glycogen accumulation in response to increased glucose concentration, which was not accompanied by changes in the growth phase. In minimal glucose medium, yegW-deficient E. coli promoted glycogen accumulation, at the expense of poor cell proliferation. We concluded that YegW is a single-target transcription factor that senses ADPG and represses glycogen accumulation in response to the amount of glucose available to the cell. We propose renaming YegW to GgaR (repressor of glycogen accumulation).

Prediction of the neurological outcomes post-cardiac arrest: A prospective validation of the CAST and rCAST.

INTRODUCTION: The neurologic prognosis of out-of-hospital cardiac arrest (OHCA) patients in whom return of spontaneous circulation (ROSC) is achieved remains poor. The aim of this study was to externally and prospectively validate two scoring systems developed by us: the CAST score, a scoring system to predict the neurological prognosis of OHCA patients undergoing targeted temperature management (TTM), and a simplified version of the same score developed for improved ease of use in clinical settings, the revised CAST (rCAST) score. METHODS: This study was a prospective, multicenter, observational study conducted using the SOS KANTO 2017 registry, an OHCA registry involving hospitals in the Kanto region (including Tokyo) of Japan. The primary outcome was favorable neurological outcome (defined as Cerebral Performance Category score of 1 or 2) at 30 days and the secondary outcomes were favorable neurological outcome at 90 days and survival at 30 and 90 days. The predictive accuracies of the original CAST (oCAST) and rCAST scores were evaluated by using area under the receiver operating characteristic curve (AUC). RESULTS: Of 9909 OHCA patients, 565 showed ROSC and received TTM. Of these, we analyzed the data of 259 patients in this study. The areas under the receiver operating characteristic curve (AUCs) of the oCAST and rCAST scores for predicting a favorable neurological outcome at 30 days were 0.86 and 0.87, respectively, and those for predicting a favorable neurological outcome at 90 days were 0.87 and 0.88, respectively. The rCAST showed a higher predictive accuracy for the neurological outcome as compared with the NULL-PLEASE score. The patients with a favorable neurological outcome who had been classified into the high severity group based on the rCAST tended to have hypothermia at hospital arrival and to not show any signs of loss of gray-white matter differentiation on brain CT. Neurological function at 90 days was correlated with the rCAST (r = 0.63, p < 0.001). CONCLUSIONS: rCAST showed high predictive accuracy for the neurological prognosis of OHCA patients managed by TTM, comparable to that of the oCAST score. The scores on the rCAST were strongly correlated with the neurological functions at 90 days, implying that the rCAST is a useful scale for assessing the severity of brain injury after cardiac arrest.

[Managing Post Cardiac Arrest Syndrome].

Four conditions occur after cardiac arrest resuscitation and are referred to as the post-cardiac arrest syndrome. Moreover, post-cardiac arrest brain injury has the greatest impact on outcomes. Brain injury can be primary as a result of global cerebral ischemia during cardiac arrest. It may be secondary(reperfusion injury)after initiation of cardiopulmonary resuscitation. After cardiac arrest resuscitation, the patient must be managed in the intensive care unit, and it is recommended to avoid hypotension(MAP<65 mmHg), hypoxemia, and hyperoxemia. Oxygen saturation should be maintained at 94%-98%, normal ventilation(35 mmHg-45 mmHg), and body temperature below 37.5℃ for 72 h after resuscitation. The administration of anticonvulsants for abnormal electroencephalograms did not significantly affect the outcome. Prognosis should be predicted within 24 h to 72 h combining physical examination, biomarkers, electrophysiology, and imaging being predictive of poor outcomes.

Intra-soft tissue and intramedullary antibiotic perfusion in combination with negative pressure wound therapy.

OBJECTIVE: Intra-soft tissue and intramedullary antibiotic perfusion (iSAP and iMAP), which combine continuous administration of antibiotic solution to the wound and negative pressure wound therapy (NPWT), have been reported to be a useful management approach for hard-to-heal ulcers in the field of orthopaedic surgery. We report the efficacy of this treatment and discuss the key points. METHOD: The recipients of this treatment had contaminated fresh severe trauma with a high risk of infection, or hard-to-heal ulcers which were expected to be difficult to manage with conventional NPWT alone. Continuous administration of 1200µg/ml of gentamicin (GM) solution to the wound was performed along with NPWT. The GM solution was administered subcutaneously using a small catheter for iSAP, while intramedullary administration used a bone marrow needle for iMAP. RESULTS: iSAP was employed in all 10 patients who took part, and iMAP in three of these patients. The average treatment time was 13.6 days with iSAP and 9.3 days with iMAP. The mean serum GM level during the therapy was 1.02µg/ml. Moderate GM-induced acute kidney injury was suspected in one case, but resolved spontaneously after GM administration was stopped. Favourable wound bed preparation was achieved in all cases without recurrence of infection. CONCLUSION: Combination with continuous suction by NPWT is able to keep the local concentration of antibiotic above the minimum inhibitory concentration of biofilm-coated bacteria within the wound. We have referred to this treatment as continuous local antibiotic perfusion. Further investigation of local pharmacodynamics in the wound and side-effects of this treatment are warranted.

Elevated blood acetoacetate levels reduce major adverse cardiac and cerebrovascular events risk in acute myocardial infarction.

Although elevated blood ketone body levels reduce major adverse cardiac and cerebrovascular events (MACCEs) risk in chronic heart failure, their relationship with acute myocardial infarction remains unknown. We investigated this relationship in patients with acute myocardial infarction. This single-institution retrospective observational study analyzed data from 114 patients with acute myocardial infarction at Nihon University Hospital from May 1, 2018, to November 1, 2022. The cut-off value of acetoacetate for the incidence of in-hospital MACCE was determined by drawing a receiver operating characteristic curve (ROC) and defining patients with acetoacetate above and below the optimal cut-off point value as ROC and low-acetoacetate (LA) groups, respectively. Propensity score matching was performed between the LA and high-acetoacetate (HA) groups. Sex, peak creatine kinase, lactate, and blood glucose were defined as confounding factors between in-hospital MACCEs and acetoacetate, and 1:1 propensity score matching between the LA and HA groups was used, resulting in 40 patients from both groups enrolled in the analysis. There was a significantly lower incidence of in-hospital MACCEs in the HA group (LA group: 9 [22%] vs HA group: 1 [3%], P = 0.014). In conclusion, in acute myocardial infarction, elevated blood acetoacetate levels reduce the risk of MACCE.

Orthopaedic trauma residency programs: Perspectives from different countries across the world.

The ability to manage the myriad of musculoskeletal conditions successfully requires multiple years of training. Access to and completion of orthopaedic surgical training entails an often grueling, highly regulated path to certification to practice. Although the world is more connected than ever, the question is whether the local certification criteria for medical specialists leads to a generic residency program and a similar training in all countries. This report from eight nations on five continents details the distinctive features of that training, including the number of positions available, the examinations required, the gender distribution of residents, and available possibilities once the residence period is complete. This analysis shows a wide variation in the orthopaedic trauma training program worldwide, with emphasis on different skills per country.

Clinical significance of reactive thrombocytosis in the course of acute pancreatitis.

BACKGROUND: Reactive thrombocytosis occurs secondary to systemic infections, inflammatory, and other conditions. The relationship between thrombocytosis and acute pancreatitis (AP) in inflammatory diseases is uncertain. This study aimed to evaluate the clinical significance of thrombocytosis in AP patients during hospitalization. METHODS: Subjects within 48 h of AP onset were consecutively enrolled over 6 years. Platelet counts of ≥ 450,000/µL were defined as thrombocytosis, < 100,000/µL as thrombocytopenia, and other counts as normal. We compared clinical characteristics, including the rate of severe AP (SAP) assessed by the Japanese Severity Score; blood markers, including hematologic and inflammatory factors and pancreatic enzymes during hospitalization; and pancreatic complications and outcomes in the three groups. RESULTS: A total of 108 patients were enrolled. Although, SAP was more common in patients with thrombocytosis and thrombocytopenia (87.9% and 100%, respectively), the differences in lymphocytes and C-reactive protein, lactase dehydrogenase, and antithrombin levels, which are factors of the systemic inflammatory response, and the mean platelet volume, an indicator of platelet activation, were observed among patients with thrombocytosis and thrombocytopenia during hospitalization. Regarding pancreatic complications and outcomes, patients with thrombocytosis and thrombocytopenia had higher acute necrotic collection (ANC), pancreatic necrosis, intestinal paralysis, respiratory dysfunction, and pancreatic-related infection levels than patients with normal platelet levels. The relationship between pancreatic complications and thrombocytosis was assessed by multivariate logistic regression; the odds ratios for development of ANC, pancreatic necrosis and pancreatic-related infections were 7.360, 3.735 and 9.815, respectively. CONCLUSIONS: Thrombocytosis during hospitalization for AP suggests development of local pancreatic complications and pancreatic-related infections.

Activities of the Japan Council for Implementation of the Maternal Emergency Life Support System reduced direct causes of maternal deaths in Japan.

Here, we aimed to provide an overview of Japan Council for the Implementation of the Maternal Emergency Life-Saving System (J-CIMELS) and its simulation program, which has reduced maternal mortality due to direct causes in Japan. The Japan Association of Obstetricians and Gynecologists (JAOG), Japan Association of Obstetricians and Gynecologists, and Maternal Death Exploratory Committee (JMDEC) launched the Maternal Death Reporting Project in 2010. The project analyzed obstetricians' tendency to delay their initial response to sudden maternal deterioration. Obstetricians can predict small changes before deterioration by monitoring vital signs. In 2015, the J-CIMELS was established to provide practical education. J-CIMELS developed a simulation program (J-MELS; Japan Maternal Emergency Life Support) to ensure that the obstetricians acquire the latest knowledge of emergency physicians, anesthesiologists, and other general practitioners and apply it in clinical situations. In the last 7 years, the J-MELS basic course has been conducted 1000 times with a total attendance of 19 890 people. As a result, the incidence of obstetric hemorrhage progressively decreased from 29% in 2010 to 7% in 2020. We believe that the activities of J-CIMELS are improving obstetric care providers' medical practices in Japan.

Multicenter study on atypical femoral fractures in patients with bone metastases taking bone- modifying agents.

Bone-modifying agents (BMAs), with bone-resorptive inhibitory effects, such as zoledronic acid and denosumab, are widely used at higher doses for bone-related events caused by bone metastasis of malignant tumors. These drugs have been suggested to be associated with atypical femoral fractures (AFFs), and the relationship between BMAs and AFFs has attracted attention. To investigate the clinical features including bone union time of AFFs in patients administered BMA for bone metastasis, we conducted a retrospective multicenter study. Thirty AFFs from 19 patients were enrolled in this study. Thirteen patients had bilateral AFFs, and nineteen AFFs had prodromal symptoms. Eighteen AFFs underwent surgery after complete fracture, three failed to achieve bone union and required nonunion surgery, and 11 AFFs that achieved bone union had an average period until bone union of 16.2 months, which was much longer than that previously reported for ordinary AFFs. Seven patients discontinued the BMAs, but not due to AFFs. Stopping BMAs in patients with bone metastasis would make it difficult to secure their performance of activities of daily living, and AFF with BMA administration might require a longer time for union. Therefore, it would be important to prevent incomplete AFF from becoming complete AFF via prophylactic internal fixation.

Surface modification enhances the bulk proton conductivity of Prussian blue.

Surface-modified Prussian blue shows 102 times higher bulk proton conductivity (0.018 S cm-1) than that of unmodified Prussian blue. This enhancement is attributed to the monolayer adsorption of Na4[Fe(CN)6] on the nanoparticle surface, which reduces the surface resistance. Surface modification is an effective strategy for improving bulk proton conductivity.

Prehospital ABC (Age, Bystander and Cardiogram) scoring system to predict neurological outcomes of cardiopulmonary arrest on arrival: post hoc analysis of a multicentre prospective observational study.

BACKGROUND: There is currently limited evidence to guide prehospital identification of patients with cardiopulmonary arrest on arrival (CPAOA) to hospital who have potentially favourable neurological function. This study aimed to develop a simple scoring system that can be determined at the contact point with emergency medical services to predict neurological outcomes. METHODS: We analysed data from patients with CPAOA using a regional Japanese database (SOS-KANTO), from January 2012 to March 2013. Patients were randomly assigned into derivation and validation cohorts. Favourable neurological outcomes were defined as cerebral performance category 1 or 2. We developed a new scoring system using logistic regression analysis with the following predictors: age, no-flow time, initial cardiac rhythm and arrest place. The model was internally validated by assessing discrimination and calibration. RESULTS: Among 4907 patients in the derivation cohort and 4908 patients in the validation cohort, the probabilities of favourable outcome were 0.9% and 0.8%, respectively. In the derivation cohort, age ≤70 years (OR 5.11; 95% CI 2.35 to 11.14), no-flow time ≤5 min (OR 4.06; 95% CI 2.06 to 8.01) and ventricular tachycardia or fibrillation as initial cardiac rhythm (OR 6.66; 95% CI 3.45 to 12.88) were identified as predictors of favourable outcome. The ABC score consisting of Age, information from Bystander and Cardiogram was created. The areas under the receiver operating characteristic curves of this score were 0.863 in the derivation and 0.885 in the validation cohorts. Positive likelihood ratios were 6.15 and 6.39 in patients with scores >2 points and were 11.06 and 17.75 in those with 3 points. CONCLUSION: The ABC score showed good accuracy for predicting favourable neurological outcomes in patients with CPAOA. This simple scoring system could potentially be used to select patients for extracorporeal cardiopulmonary resuscitation and minimise low-flow time.

Maternal cardiopulmonary resuscitation.

The perinatal resuscitation history in Japan is short, with the earliest efforts in the field of neonatology. In contrast, the standardization and dissemination of maternal resuscitation is lagging. With the establishment of the Maternal Death Reporting Project and the Maternal Death Case Review and Evaluation Committee in 2010, with the aim of reducing maternal deaths, the true situation of maternal deaths came to light. Subsequently, in 2015, the Japan Council for the Dissemination of Maternal Emergency Life Support Systems (J-CIMELS) was established to educate and disseminate simulations in maternal emergency care; training sessions on maternal resuscitation are now conducted in all prefectures. Since the launch of the project and council, the maternal mortality rate in Japan (especially due to obstetric critical hemorrhage) has gradually decreased. This has been probably achieved due to the tireless efforts of medical personnel involved in perinatal care, as well as the various activities conducted so far. However, there are no standardized guidelines for maternal resuscitation yet. Therefore, a committee was set up within the Japan Resuscitation Council to develop a maternal resuscitation protocol, and the Guidelines for Maternal Resuscitation 2020 was created in 2021. These guidelines are expected to make the use of high-quality resuscitation methods more widespread than ever before. This presentation will provide an overview of the Guidelines for Maternal Resuscitation 2020.

An epidemiological assessment of choking-induced out-of-hospital cardiac arrest: A post hoc analysis of the SOS-KANTO 2012 study.

OBJECTIVES: The aim of this study was to reveal the neurological outcomes of choking-induced out-of-hospital cardiac arrest (OHCA) and evaluate the presence of witnesses, cardiopulmonary resuscitation (CPR) performed by a witness (bystander-witnessed CPR), and the proportion of patients with favourable neurological outcomes by the time from CPR by emergency medical services (EMS) to the return of spontaneous circulation (ROSC) (CPR-ROSC time). METHODS: We retrospectively analysed the SOS-KANTO 2012 database, which included data of 16,452 OHCAs in Japan. We selected choking-induced OHCA patients aged ≥ 20 years. We evaluated the neurological outcomes at 1 month with the Cerebral Performance Category (CPC). We defined favourable neurological outcomes (CPCs: 1-2) and present the outcomes with descriptive statistics. RESULTS: Of 1,045 choking-induced OHCA patients, 18 (1.7%) had a favourable neurological outcome. Of 1,045 OHCAs, 757 (72.6%) were witnessed, and 375 (36.0%) underwent bystander-witnessed CPR. Of the 18 OHCAs with favourable outcomes, 17 (94.4%) were witnessed, and 11 (61.1%) underwent bystander-witnessed CPR. With a CPR-ROSC time of 0-5 minutes, the proportion of patients with favourable neurological outcomes was 29.7%, ranging from 0% to 6% in the following time groups. CONCLUSIONS: The neurological outcome of choking-induced OHCA was poor. The neurological outcomes deteriorated rapidly from 5 minutes after the initiation of CPR by EMS. The presence of witnesses and bystander-witnessed CPR may be factors that contribute to improved outcomes, but the effects were not remarkable. As another approach to reduce deaths due to choking, citizen education for the prevention of choking may be effective.

Heart Rate and Mortality After Resuscitation in Patients With Out-of-Hospital Cardiac Arrest　- Insights From the SOS-KANTO Registry.

BACKGROUND: Heart rate (HR) predicts outcomes in patients with acute coronary syndrome (ACS), whereas the impact of HR on outcomes after out-of-hospital cardiac arrest (OHCA) remains unclear. This study aimed to investigate the impact of HR after resuscitation on outcomes after OHCA and whether the impact differs with OHCA etiology.Methods and Results: Of 16,452 patients suffering from OHCA, this study analyzed 741 adults for whom HR after resuscitation was recorded by 12-lead electrocardiogram upon hospital arrival. Etiology of OHCA was categorized into 3 groups: ACS, non-ACS, and non-cardiac. Patients in each etiology group were further divided into tachycardia (>100 beats/min) and non-tachycardia (≤100 beats/min). The impact of HR on outcomes was evaluated in each group. Among the 741 patients, the mean age was 67.6 years and 497 (67.1%) patients were male. The primary outcome - 3-month all-cause mortality - was observed in 55.8% of patients. Tachycardia after resuscitation in patients with ACS was significantly associated with higher all-cause mortality at 3 months (P=0.002), but there was no significant association between tachycardia and mortality in non-ACS and non-cardiac etiology patients. In a multivariate analysis model, the incidence of tachycardia after resuscitation independently predicted higher 3-month all-cause mortality in OHCA patients with ACS (hazard ratio: 2.17 [95% confidence interval: 1.05-4.48], P=0.04). CONCLUSIONS: Increased HR after resuscitation was associated with higher mortality only in patients with ACS.

ABCD approach at the #7119 center, telephone triage system in Tokyo, Japan; a retrospective cohort study.

BACKGROUND: The algorithm and protocol of the #7119 telephone triage in Tokyo, Japan, had been originally established and consists of three steps. In this study, we investigated the outcome of patients treated with physiological abnormality (ABCD approach: A, airway; B, breathing; C, circulation, and D, dysfunction of central nervous system) in step 2 during the #7119 telephone triage and clarified the meaning of evaluation of this approach. METHODS: We retrospectively reviewed data from the Tokyo Fire Department from January 2016 to December 2017. Almost all the patients triaged using the ABCD approach were transferred to the hospital by ambulance and assigned severity by a physician. We divided patients into groups with combinations of 15 patterns including A, B, C, D, AB, AC, AD, BC, BD, CD, ABC, ABD, ACD, BCD, and ABCD. We compared the proportion of severe cases in each group using a Fisher's exact test, followed by residual analysis. RESULTS: We analyzed 13,793 cases triaged using the ABCD approach. In this analysis, 31% of total cases were assessed as severe cases. Groupwise analysis showed that the proportion of severe cases was significantly higher in the AD, BC, CD, ABD, and ABCD groups, while it was significantly less in the C and AB groups than in the total cases. CONCLUSION: At the #7119 telephone triage, we can pick up the severe cases by the ABCD approach. This may contribute to the prompt transportation of severe patients to hospitals by dispatching ambulance cars using the #7119 telephone triage methods.

Effect of maternal positioning during cardiopulmonary resuscitation: a systematic review and meta-analyses.

BACKGROUND: Although rare, cardiac arrest during pregnancy is the leading cause of maternal death. Recently, its incidence has been increasing worldwide because more pregnant women have risk factors. The provision of early, high-quality cardiopulmonary resuscitation (CPR) plays a major role in the increased likelihood of survival; therefore, it is important for clinicians to know how to manage it. Due to the aortocaval compression caused by the gravid uterus, clinical guidelines often emphasise the importance of maternal positioning during CPR, but there has been little evidence regarding which position is most effective. METHODS: We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, and OpenGrey (updated on April 3, 2021). We included clinical trials and observational studies with reported outcomes related to successful resuscitations. RESULTS: We included eight studies from the 1,490 screened. The eight studies were simulation-based, crossover trials that examine the quality of chest compressions. No data were available about the survival rates of mothers or foetuses/neonates. The meta-analyses showed that resuscitation of pregnant women in the 27°-30° left-lateral tilt position resulted in lower quality chest compressions. The difference is an 19% and 9% reduction in correct compression depth rate and correct hand position rate, respectively, compared with resuscitations in the supine position. Inexperienced clinicians find it difficult to perform chest compressions in the left-lateral tilt position. CONCLUSIONS: Given that manual left uterine displacement allows the patient to remain supine, the resuscitation of women in the supine position using manual left uterine displacement should continue to be supported. Further research is needed to fill knowledge gaps regarding the effects of maternal positioning on clinical outcomes, such as survival rates following maternal cardiac arrest.

Elevated INR in a COVID-19 patient after concomitant administration of favipiravir and warfarin: A case report.

WHAT IS KNOWN AND OBJECTIVE: Favipiravir is a promising treatment candidate for managing coronavirus disease 2019 (COVID-19). Warfarin has many drug interactions, but no interactions with favipiravir have been reported. CASE SUMMARY: Our patient was taking warfarin for deep vein thrombosis. The international normalized ratio (INR) was stable (1.65 to 2.0); however, it increased to 4.63 after administering favipiravir. The patient had no other factors justifying this change. WHAT IS NEW AND CONCLUSION: Favipiravir and warfarin might have previously unidentified drug interactions that elevated the INR. Therefore, INR must be closely monitored when they are concomitantly administered in COVID-19 patients.

External validation of simplified out-of-hospital cardiac arrest and cardiac arrest hospital prognosis scores in a Japanese population: a multicentre retrospective cohort study.

BACKGROUND: The novel simplified out-of-hospital cardiac arrest (sOHCA) and simplified cardiac arrest hospital prognosis (sCAHP) scores used for prognostication of hospitalised patients have not been externally validated. Therefore, this study aimed to externally validate the sOHCA and sCAHP scores in a Japanese population. METHODS: We retrospectively analysed data from a prospectively maintained Japanese database (January 2012 to March 2013). We identified adult patients who had been resuscitated and hospitalised after intrinsic out-of-hospital cardiac arrest (OHCA) (n=2428, age ≥18 years). We validated the sOHCA and sCAHP scores with reference to the original scores in predicting 1-month unfavourable neurological outcomes (cerebral performance categories 3-5) based on the discrimination and calibration measures of area under the receiver operating characteristic curves (AUCs) and a Hosmer-Lemeshow goodness-of-fit test with a calibration plot, respectively. RESULTS: In total, 1985/2484 (82%) patients had a 1-month unfavourable neurological outcome. The original OHCA, sOHCA, original cardiac arrest hospital prognosis (CAHP) and sCAHP scores were available for 855/2428 (35%), 1359/2428 (56%), 1130/2428 (47%) and 1834/2428 (76%) patients, respectively. The AUCs of simplified scores did not differ significantly from those of the original scores, whereas the AUC of the sCAHP score was significantly higher than that of the sOHCA score (0.88 vs 0.81, p<0.001). The goodness of fit was poor in the sOHCA score (ν=8, χ2=19.1 and Hosmer-Lemeshow test: p=0.014) but not in the sCAHP score (ν=8, χ2=13.5 and Hosmer-Lemeshow test: p=0.10). CONCLUSION: The performances of the original and simplified OHCA and CAHP scores in predicting neurological outcomes in successfully resuscitated OHCA patients were acceptable. With the highest availability, similar discrimination and good calibration, the sCAHP score has promising potential for clinical implementation, although further validation studies to evaluate its clinical acceptance are necessary.