Impact of the COVID-19 pandemic on management and outcomes of patients with acute heart failure.

AIMS: Guidelines recommend non-invasive positive pressure ventilation (NPPV) for patients with acute decompensated heart failure (ADHF) with an inadequate response to initial oxygen therapy. During Japan's coronavirus disease 2019 pandemic, NPPV use in emergency departments (EDs) was limited due to aerosol-spreading concerns. This study compared the respiratory management and clinical outcomes of patients with ADHF in EDs before and during the pandemic. METHODS AND RESULTS: This retrospective cohort study was conducted at a single centre in Japan using hospital data from September to November 2019 (before the pandemic) and September to November 2020 (during the pandemic). Patients diagnosed with ADHF were included. Patients not responding to standard oxygen therapy were intubated or started on NPPV therapy. The primary outcome measure was discharge after death. The secondary outcomes were length of hospital stay and medical expenses. The study included 37 patients before the pandemic and 36 during the pandemic. No significant differences were found in vital signs or laboratory data between the groups. NPPV utilization decreased significantly from 26 (70.3%) to 7 (19.4%) (P < 0.01). Two patients required intubation during both periods, with no significant differences (P = 0.98). No significant intergroup disparities were observed in discharge after death (1/36 [2.7%] vs. 1/37 [2.7%]; P = 0.19), length of hospital stay (17.5 vs. 19.0 days; P = 0.65), and medical expenses (57 590 vs. 57 600 yen; P = 0.65). CONCLUSIONS: Despite a large decrease in NPPV use before and during the pandemic, there were no significant differences in discharge after death, hospital stay, or medical expenses.

Evaluation of the holding-up uterus technique for placenta accreta spectrum cesarean hysterectomy in shocked patients with a high shock index: a case series study.

BACKGROUND: Placenta accreta spectrum (PAS) cesarean hysterectomy is performed under conditions of shock and can result in serious complications. This study aimed to evaluate the usefulness of the "Holding-up uterus" surgical technique with a shock index (S.I.) > 1.5. METHODS: Twelve patients who underwent PAS cesarean hysterectomy were included in the study. RESULTS: Group I had S.I. > 1.5, and group II had S.I. ≤ 1.5. Group I had more complications, but none were above Grade 3 or fatal. Preoperative scheduled uterine artery embolization did not result in serious complications, but three patients who had emergency common iliac artery balloon occlusion (CIABO) and a primary total hysterectomy with S.I. > 1.5 had postoperative Grade 2 thrombosis. Two patients underwent manual ablation of the placenta under CIABO to preserve the uterus, both with S.I. > 1.5. CONCLUSIONS: The study found that the "Holding-up uterus" technique was safe, even in critical situations with S.I. > 1.5. CIABO had no intervention effect. The study also identified assisted reproductive technology pregnancies with a uterine cavity length of less than 5 cm before conception as a critical factor.

Corrigendum: Association of airway obstruction with first-pass success and intubation-related adverse events in the emergency department: multicenter prospective observational studies.

[This corrects the article DOI: 10.3389/fmed.2023.1199750.].

Factors for delays in door-to-balloon time ≤ 90 min in an electrocardiogram triage system among patients with ST-segment elevation myocardial infarction: a retrospective study.

BACKGROUND: Door to balloon time is a crucial factor of mortality in patients with ST-segment elevation myocardial infarction. However, the factors that contribute to failure of achieving door to balloon time ≤ 90 min in an electrocardiogram triage system remain unknown. METHODS: This single-center retrospective observational study collected data from consecutive patients with ST-segment elevation myocardial infarction from April 2016 to March 2021. The primary outcome was the failure to achieve door to balloon time ≤ 90 min. A multivariate logistic regression model was performed to predict factors associated with failure to achieve door to balloon time ≤ 90 min. RESULTS: In total, 190 eligible patients were included. Of these, the 139 (73.2%) patients with door to balloon time ≤ 90 min were significantly younger compared to those with door to balloon time > 90 min (p = 0.02). However, there was no significant difference in sex and timing of hospital arrival between the door to balloon time ≤ 90 and > 90 min groups. Presence of chest pain and ambulance usage were significantly more frequent in patients with door to balloon time ≤ 90 min (p ≤ 0.01, p = 0.02, respectively). Multivariate analysis showed that absence of chest pain (adjusted odds ratio 4.76; 95% confidence interval, 2.04-11.1; p < 0.01) and non-ambulance usage (adjusted odds ratio 3.53; 95% confidence interval, 1.57-7.94; p < 0.01) are predictive factors of failure to achieve door to balloon time ≤ 90 min. CONCLUSION: Patients without chest pain as the chief complaint or non-ambulance usage were significantly associated with the failure to achieve door to balloon time ≤ 90 min.

Association between capnography and recovery time after procedural sedation and analgesia in the emergency department.

Aim: Capnography is recommended for use in procedural sedation and analgesia (PSA); however, limited studies assess its impact on recovery time. We investigated the association between capnography and the recovery time of PSA in the emergency department (ED). Methods: This study was a secondary analysis of a multicenter PSA patient registry including eight hospitals in Japan. We included all patients who received PSA in the ED between May 2017 and May 2021 and divided the patients into capnography and no-capnography groups. The primary outcome was recovery time, defined as the time from the end of the procedure to the cessation of monitoring. The log-rank test and multivariable analysis using clustering for institutions were performed. Results: Of the 1265 screened patients, 943 patients who received PSA were enrolled and categorized into the capnography (n = 150, 16%) and no-capnography (n = 793, 84%) groups. The median recovery time was 40 (interquartile range [IQR]: 25-63) min in the capnography group and 30 (IQR: 14-55) min in the no-capnography group. In the log-rank test, the recovery time was significantly longer in the capnography group (p = 0.03) than in the no-capnography group. In the multivariable analysis, recovery time did not differ between the two groups (adjusted hazard ratio, 0.95; 95% confidence interval, 0.77-1.17; p = 0.61). Conclusion: In this secondary analysis of the multicenter registry of PSA in Japan, capnography use did not associate with shorter recovery time in the ED.

Association of airway obstruction with first-pass success and intubation-related adverse events in the emergency department: multicenter prospective observational studies.

Background: Airway obstruction is a relatively rare but critical condition that requires urgent intervention in the emergency department (ED). The present study aimed to investigate the association of airway obstruction with first-pass success and intubation-related adverse events in the ED. Methods: We analyzed data from two prospective multicenter observational studies of ED airway management. We included adults (aged ≥18 years) who underwent tracheal intubation for non-trauma indications from 2012 through 2021 (113-month period). Outcome measures were first-pass success and intubation-related adverse events. We constructed a multivariable logistic regression model adjusting for age, sex, modified LEMON score (without airway obstruction), intubation methods, intubation devices, bougie use, intubator's specialty, and ED visit year with accounting for patients clustering within the ED. Results: Of 7,349 eligible patients, 272 (4%) underwent tracheal intubation for airway obstruction. Overall, 74% of patients had first-pass success and 16% had intubation-related adverse events. The airway obstruction group had a lower first-pass success rate (63% vs. 74%; unadjusted odds ratio [OR], 0.63; 95% CI, 0.49-0.80), compared to the non-airway obstruction group. This association remained significant in the multivariable analysis (adjusted OR 0.60, 95%CI 0.46-0.80). The airway obstruction group also had a significantly higher risk of adverse events (28% vs. 16%; unadjusted OR, 1.93; 95% CI, 1.48-2.56, adjusted OR, 1.70; 95% CI, 1.27-2.29). In the sensitivity analysis using multiple imputation, the results remained consistent with the main results: the airway obstruction group had a significantly lower first-pass success rate (adjusted OR, 0.60; 95% CI, 0.48-0.76). Conclusion: Based on these multicenter prospective data, airway obstruction was associated with a significantly lower first-pass success rate and a higher intubation-related adverse event rate in the ED.

Association of antiplatelet or anticoagulant agents with in-hospital mortality among blunt torso trauma patients without severe traumatic brain injury: A retrospective analysis of the Japanese nationwide trauma registry.

AIM: Patients with head trauma who take antiplatelet or anticoagulant (APAC) agents have a higher rate of mortality. However, the association between these agents and mortality among blunt torso trauma patients without severe traumatic brain injury remains unclear. METHODS: Using the Japanese nationwide trauma registry, we conducted a retrospective cohort study including adult patients with blunt torso trauma without severe head trauma between January 2019 and December 2020. Eligible patients were divided into two groups based on whether or not they took any APAC agents. The primary outcome was in-hospital mortality. To adjust for potential confounding factors, we conducted random effects logistic regression to account for patients clustering within the hospitals. The model was adjusted for potential confounders, including age, mechanism of injury, Charlson comorbidity index, systolic blood pressure, and injury severity scale on arrival as potentially confounding factors. RESULTS: During the study period, 16,201 patients were eligible for the analysis. A total of 832 patients (5.1%) were taking antiplatelet or anticoagulant agents. Overall in-hospital mortality was 774 patients (4.8%). APAC group had a higher risk of in-hospital mortality compared with the non-APAC group (6.9% vs. 4.7%; unadjusted OR, 1.51; 95% CI, 1.12-2.00; P < 0.01). After adjusting for potential confounder, there were no significant intergroup difference in a higher in-hospital mortality compared to with the non-APAC group (OR, 1.07; 95%CI, 0.65-1.77; P = 0.79). CONCLUSION: The use of APAC agents before the injury was not associated with higher in-hospital mortality among blunt torso trauma patients without severe traumatic brain injury.

Changes in the Treatment for Out-of-Hospital Cardiac Arrest During the Initial Stage of the COVID-19 Outbreak in Japan.

INTRODUCTION: Cardiopulmonary resuscitation (CPR) for out-of-hospital cardiac arrest (OHCA) patients during the coronavirus disease 2019 (COVID-19) pandemic carries an added risk of COVID-19 infection for healthcare workers. However, because of the shortage of medical supplies and limited evidence of COVID-19 in the initial stages of the pandemic, strategies for the management of OHCA patients may have varied across hospitals. METHOD: A web-based questionnaire was used. The first section collected data about physician characteristics. In the second section, participants responded "Yes" or "No," if they had made changes in the areas of "personal protective equipment (PPE)" or "CPR Algorithm" for OHCA patients (these changes were the personal views of the surveyed respondents). The questionnaire was sent to the members of the Emergency Medicine Alliance mailing list. The response period was from May 22 to June 5, 2020 (the first state of emergency related to COVID-19 was declared on April 7, 2020, in Japan). Participants were asked to indicate their stress level resulting from these changes using the Likert scale ranging from 1 to 10, where 1 = "no stress" and 10 = "severe stress." RESULT: A total of 110 physicians responded during the study period. The majority of participants reported changes in "PPE" (n = 106, 96.4%) and "CPR Algorithm" (n = 86, 78.2%). The reported stress level due to changes in PPE was 8 (IQR 6-9) and due to changes in the CPR algorithm, it was 7 (IQR 5-8). CONCLUSION: Findings of this study suggest that physicians experienced changes in care for OHCA patients and felt stress during the initial stage of the COVID-19 pandemic. Thus, it would be better to list the actual measures that can be undertaken to prepare for any future pandemics.

Association of advanced age with intubation-related adverse events in the emergency department: a multicentre prospective observational study.

BACKGROUND: While the older population accounts for an increasing proportion of emergency department (ED), little is known about intubation-related adverse events in this high-risk population. We sought to determine whether advanced age is associated with a higher risk of intubation-related adverse events in the ED. METHODS: This is an analysis of data from a prospective, 15-centre, observational study-the second Japanese Emergency Airway Network (JEAN-2) study. The current analysis included adult (aged ≥18 years) patients who underwent intubation in the ED between 2012 and 2018. The primary exposure was age (18-39, 40-64, 65-74, 75-84 and ≥85 years). The primary outcome was overall intubation-related adverse events during or immediately after an intubation. Adverse events were further categorised into major (hypotension, hypoxaemia, oesophageal intubation, cardiac arrest, dysrhythmia and death) and minor (endobronchial intubation, oesophageal intubation with early recognition, dental/lip trauma, airway trauma and regurgitation) adverse events. We constructed multivariable logistic regression models adjusting for seven potential confounders with generalised estimating equations that account for patients clustering within the ED. RESULTS: Among 9714 patients eligible for the analysis, 15% were aged ≥85 years, and 16% had adverse events. In the unadjusted models, advanced age was not significantly associated with the risk of overall adverse events. In the adjusted models, the association was significant (adjusted OR 1.41 in age ≥85 years (95% CI, 1.09 to 1.81) compared with age 18-39 years). Specifically, older patients had a significantly higher risk of major adverse events (adjusted OR in age ≥85 years 2.65 (95% CI, 1.78 to 3.94)), which was driven by the association of advanced age with an increased risk of hypotension (adjusted OR in ≥85 years, 5.69 (95% CI, 3.13 to 10.37)). By contrast, advanced age was not associated with minor adverse events. CONCLUSION: Based on the data from a prospective multicentre study, advanced age was associated with higher risks of major adverse events.

Author Correction: Association of ketamine use with lower risks of post-intubation hypotension in hemodynamically-unstable patients in the emergency department.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Association of ketamine use with lower risks of post-intubation hypotension in hemodynamically-unstable patients in the emergency department.

To determine whether ketamine use for tracheal intubation, compared to other sedative use, is associated with a lower risk of post-intubation hypotension in hemodynamically-unstable patients in the emergency department (ED), we analyzed the data of a prospective, multicenter, observational study-the second Japanese Emergency Airway Network (JEAN-2) Study-from February 2012 through November 2017. The current analysis included adult non-cardiac-arrest ED patients with a pre-intubation shock index of ≥0.9. The primary exposure was ketamine use as a sedative for intubation, with midazolam or propofol use as the reference. The primary outcome was post-intubation hypotension. A total of 977 patients was included in the current analysis. Overall, 24% of patients developed post-intubation hypotension. The ketamine group had a lower risk of post-intubation hypotension compared to the reference group (15% vs 29%, unadjusted odds ratio [OR] 0.45 [95% CI 0.31-0.66] p < 0.001). This association remained significant in the multivariable analysis (adjusted OR 0.43 [95% CI 0.28-0.64] p < 0.001). Likewise, in the propensity-score matching analysis, the patients with ketamine use also had a significantly lower risk of post-intubation hypotension (OR 0.47 [95% CI, 0.31-0.71] P < 0.001). Our observations support ketamine use as a safe sedative agent for intubation in hemodynamically-unstable patients in the ED.

New D-dimer threshold for Japanese patients with suspected pulmonary embolism: a retrospective cohort study.

BACKGROUND: In the diagnosis of pulmonary embolism (PE), the D-dimer threshold is based on studies conducted in Western countries, where the incidence rate is 5 times higher than that in Asian countries, including Japan. If we could elevate the D-dimer threshold based on the low pre-test probability in the Japanese population, we could omit the computed tomography pulmonary angiography (CTPA) which might lead to radiation exposure and contrast-induced nephropathy. Therefore, we aimed to determine a new D-dimer threshold specific to Japanese individuals. METHODS: We conducted a retrospective cohort study at an emergency department in Japan, using medical charts collected from January 2013 to July 2017. We included patients whose D-dimer were measured for suspicion of PE with low or intermediate probability of PE and CTPA were performed. The primary outcome was failure rate of the new D-dimer threshold, defined as the rate of PE detected by CTPA among patients with D-dimer under the new threshold ranging from 1000 to 1500 µg/L by 100. The new D-dimer threshold was appropriate if the upper limit of 95% confidence interval of the failure rate of PE was approximately 3%. RESULTS: In 395 patients included, the number of patients with PE was 24 (the prevalence was 6.1%). If the D-dimer threshold was 1100 µg/L, the failure rate was 0% (0/119), the upper limit of the 95% confidence interval of the failure rate was 3.1%, and 30% (119/395) of the CTPA might be omitted. CONCLUSION: The new D-dimer threshold could safely exclude PE. This result can be generalized to other Asian populations with a lower incidence of PE. Further prospective studies will be needed.

Unique characteristics of frequent presenters to the emergency department in a Japanese population: a retrospective analysis.

AIM: Little evidence on Japanese frequent presenters (FPs) is available. Therefore, this retrospective cohort study compared characteristics between FPs and non-frequent presenters (NFPs) in emergency departments (EDs) in Japan. METHODS: Frequent presenters included those who presented to an ED ≥4 times during the study period from August 1, 2012 to July 21, 2013. The primary outcomes were triage level and disposition. Secondary outcomes were ED length of stay, method of arrival, and discharge diagnosis. RESULTS: During the study period, 195 FPs had 1,154 visits to the ED, compared to 15,953 visits by 13,838 NFPs. The sex distribution between FPs and NFPs was comparable (107 men [54.9%] versus 7,070 men [51.1%], respectively; P = 0.29), but the mean age was significantly higher in the FP group (57.3 versus 46.5 years, respectively; P < 0.0001). Among the FPs, the rate of free governmental health insurance was higher than that of those who pay 30% of health costs (35 patients paid 0% [79.5%] versus 109 patients paid 30% [42.6%], respectively). Condition severity (FP, 84 severe cases [7.28%]; NFP, 1,320 severe cases [8.27%], respectively) and rate of admission (FP, 207 admissions [17.9%]; NFP, 2,987 admissions [18.7%], respectively) were comparable between the groups, although the rate of ambulance use was lower for the FP group. The most frequent diagnostic codes (International Classification of Diseases, 10th Revision) in the FP group were "symptoms and signs". CONCLUSION: Triage levels and hospital admission rates were not significantly different between FPs and NFPs in this single-center study in Japan.

Association of the Number of a Simulation Faculty With the Implementation of Simulation-Based Education.

INTRODUCTION: Although the implementation of simulation-based education (SBE) is essential for emergency medicine residency programs (EMRPs), little is known about the factors associated with its degree of SBE implementation in EMRPs. Therefore, this study aimed to investigate factors associated with SBE implementation in EMRPs. We hypothesized that the number of the simulation faculty was associated with the degree of SBE implementation. METHODS: We conducted a multicenter, cross-sectional survey on SBE implementation in emergency medicine resident education, in accredited EMRPs in the Greater Tokyo area, Japan. Survey question themes included institutional characteristics and the status of simulation education in them. For analyzing factors associated with SBE implementation, we defined EMRPs with a robust SBE implementation as those having an annual simulation time exceeding 10 hours. RESULTS: The survey response rate was 73% (115/158). Of the EMRPs that responded, 32% reported that their annual simulation time was more than 10 hours. In the unadjusted analysis, possession of a simulator in the emergency department was significantly associated with nonrobust SBE implementation, but the number of the simulation faculty was significantly associated. On adjusting for possession of a simulator in the emergency department, presence of simulation curriculum, and presence of simulation-based formative or comprehensive assessment, we observed an association of robust SBE implementation with a number of the simulation faculty (unit odds ratio = 1.33; 95% confidence interval = 1.10-1.60). CONCLUSIONS: To our knowledge, this is the first Japanese study to demonstrate that the number of the simulation faculty at a program is independently associated with a robust SBE implementation.

Association of fentanyl use in rapid sequence intubation with post-intubation hypotension.

BACKGROUND: The anesthesia literature has reported that pre-intubation fentanyl use is associated with post-intubation hypotension which is a risk factor of poor post-emergency department (ED) prognosis. However, little is known about the relations between fentanyl use for intubation and post-intubation hypotension in the ED. We aimed to determine whether pretreatment with fentanyl was associated with a higher risk of post-intubation hypotension in the ED. METHODS: We conducted a secondary analysis of data of ED airway management collected from a multicenter prospective study of 14 Japanese EDs from February 2012 through November 2016. We included all adult non-cardiac-arrest patients who underwent rapid sequence intubation for medical indication. Patients were divided into fentanyl and non-fentanyl groups. The primary outcome was post-intubation hypotension (systolic blood pressure ≤90mmHg) in the ED. RESULTS: Of 1263 eligible patients, 466 (37%) patients underwent pretreatment with fentanyl. The fentanyl group had a higher risk of post-intubation hypotension (17% vs. 6%; unadjusted OR, 1.73; 95%CI, 1.01-2.97; P=0.048) compared to the non-fentanyl group. In the multivariable analysis adjusting for age, sex, weight, principal indication, sedatives, intubator's specialty, number of intubation attempts, and patient clustering within EDs, the fentanyl group had a higher risk of post-intubation hypotension (adjusted OR, 1.87; 95%CI, 1.05-3.34; P=0.03) compared to the non-fentanyl group. In the sensitivity analysis using propensity score matching, this association remained significant (OR, 3.17; 95%CI, 1.96-5.14; P<0.01). CONCLUSION: In this prospective multicenter study of ED airway management, pretreatment with fentanyl in rapid sequence intubation was associated with higher risks of post-intubation hypotension.

Evaluation of retained products of conception using pulsed continuous arterial spin-labeling MRI: clinical feasibility and initial results.

OBJECTIVES: We evaluated the vascularity of retained products of conception (RPOC) using arterial spin-labeling magnetic resonance imaging (ASL-MRI) to clarify the clinical feasibility of this approach. MATERIALS AND METHODS: A pulsed-continuous ASL sequence with echo-planar imaging (EPI) acquisitions was used. Ten consecutive patients with RPOC were enrolled. All ASL images were evaluated visually and semiquantitatively and compared with the findings of Doppler ultrasound (US) and dynamic contrast-enhanced MRI (DCE-MRI). RESULTS: The technical success rate was 93.7% (15/16 scans). One failed case was excluded from the analysis. Six patients showed quite high signals over RPOC, while three patients showed no abnormal signals. Doppler US alone failed to detect the hypervascular area in two cases, and ASL-MRI alone failed in three. A significant linear correlation was found between semiquantitative values of ASL-MRI and DCE-MRI. All six patients showing high signals on ASL-MRI underwent follow-up MRI after therapy. High signals in five patients decreased visually and semiquantitatively, while one patient showed signal increases. CONCLUSION: Evaluation of RPOC using ASL-MRI was clinically feasible and response to therapy could be evaluated. However, the clinical advantages over conventional imaging remain unclear and need to be evaluated.