Toshikazu Abe

On examination, the patient's temperature was 37.1°C. There was significant submucosal haematoma above the soft and hart plates. Purpura was identified on the right dorsal foot. In laboratory data, haemoglobin was 6.2 g/L and prothrombin time-international normalised ratio was 19.95. The patient was subsequently admitted and the laryngoscopy showed sub-mucosal haematoma from the posterior wall of the pharynx to the piriform recess (figure 1A, B). He received red cell transfusion and vitamin K, without any intervention. On the second day of admission, PT-INR was reduced to 1.8. A second-look laryngoscopy on the seventh day showed that the haematoma had significantly reduced. On the 12th day, the patient was discharged home, without a sequel.

Aim: The aim of this study was to analyze the relationship between polypharmacy and hospital admission in ambulance‐transported old‐old patients.Methods: A retrospective cohort study was conducted of consecutive old‐old patients (aged ≥ 85 years) transported by ambulance to a community teaching hospital between April and December of 2013. Patients with out‐of‐hospital cardiopulmonary arrest were excluded. Data were collected from the computerized records on the demographics, chief complaints, vital signs, and level of consciousness at arrival, final diagnoses at discharge, and polypharmacy (≥5 medications). The primary outcome was requirement of hospital admission. We also analyzed symptomatic adverse drug events (ADEs).Results: Of the 3,084 adults (aged ≥ 18 years) transported to the hospital during the study period, 381 (13%) were old‐old patients. Of those, 233 (61%) were women, and 261 (69%) were admitted to the hospital. The mean number of their baseline medications was 6.8 ± 3.9, and 250/347 patients (72%) were suffering from polypharmacy. Twenty‐seven of the patients (7%) had symptomatic ADEs. Although the ADEs were not related to polypharmacy (P = 0.437), logistic regression adjustments for age, sex, and vital signs at arrival showed that patients with polypharmacy were more likely to be admitted to the hospital than were patients without (odds ratio: 2.12 [95% CI, 1.03–4.43]; P = 0.042).Conclusions: Symptomatic ADEs due to polypharmacy were one of the most preventable causative factors leading to hospital admission of old‐old patients. Polypharmacy could be a major risk for emergency admission to hospital.

It has been recommended that all survivors of out-of-hospital cardiac arrest (OHCA) have immediate coronary angiography (CAG), even though it has been reported that half of the survivors have normal coronary arteries. Our aim was to develop a model which might identify those who have angiographically normal coronary arteries. Reliable prediction would reduce unnecessary CAG. A retrospective, observational, cohort study was conducted on 47 consecutive adult survivors who received immediate CAG after resuscitation from OHCA, between June 1, 2006 and March 31, 2011. We analyzed the clinical and electrocardiographic characteristics of the survivors with and without normal coronary arteries. All subjects had CAG. Normal coronary arteries were found in 25/47. These persons did not have diabetes mellitus (p = 0.0069) or a history of acute coronary syndrome (ACS) (p = 0.0069). Any abnormality of the ST segment or ST segment elevation on electrocardiogram (ECG) was strongly related to abnormal coronary arteries (p = 0.0045 and p = 0.0200, respectively). The partitioning model for predicting angiographically normal coronary arteries showed that all patients (8/8) with no ST segment change on their ECG had normal coronary arteries. Eight out of ten patients with ST segment abnormalities also had normal coronary arteries with a history of arrhythmia without a history of ACS. Survivors of OHCA who have no history of diabetes mellitus, who have no past history of ACS, and who present with no ST segment abnormalities may not require urgent/emergent CAG. Further studies are needed to guide clinicians in the determination of emergent cardiac catheterization following resuscitation of OHCA.

Introduction: Helicopter emergency medical services with a physician (HEMS) has been provided in Japan since 2001. However, HEMS and its possible effect on outcomes for severe trauma patients have still been debated as helicopter services require expensive and limited resources. Our aim was to analyze the association between the use of helicopters with a physician versus ground services and survival among adults with serious traumatic injuries. Methods: This multicenter prospective observational study involved 24,293 patients. All patients were older than 15 years of age, had sustained blunt or penetrating trauma and had an Injury Severity Score (ISS) higher than 15. All of the patient data were recorded between 2004 and 2011 in the Japan Trauma Data Bank, which includes data from 114 major emergency hospitals in Japan. The primary outcome was survival to discharge from hospitals. The intervention was either transport by helicopter with a physician or ground emergency services. Results: A total of 2,090 patients in the sample were transported by helicopter, and 22,203 were transported by ground. Overall, 546 patients (26.1%) transported by helicopter died compared to 5,765 patients (26.0%) transported by ground emergency services. Patients transported by helicopter had higher ISSs than those transported by ground. In multivariable logistic regression, helicopter transport had an odds ratio (OR) for survival to discharge of 1.277 (95% confidence interval (CI), 1.049 to 1.556) after adjusting for age, sex, mechanism of injury, type of trauma, initial vital signs (including systolic blood pressure, heart rate and respiratory rate), ISS and prehospital treatment (including intubation, airway protection maneuver and intravenous fluid). In the propensity score–matched cohort, helicopter transport was associated with improved odds of survival compared to ground transport (OR, 1.446; 95% CI, 1.220 to 1.714). In conditional logistic regression, after adjusting for prehospital treatment (including intubation, airway protection maneuver and intravenous fluid), similar positive associations were observed (OR, 1.230; 95% CI, 1.017 to 1.488). Conclusions: Among patients with major trauma in Japan, transport by helicopter with a physician may be associated with improved survival to hospital discharge compared to ground emergency services after controlling for multiple known confounders.

A 59-year-old man with end-stage renal disease was brought to our emergency department with complaints of headache, nausea, dysarthria, tic, and weakness involving the bilateral arms and legs. He had the similar episode 4 month before, when he was treated elsewhere. The patient had received hemodialysis three times per week. His medications included for hypertension. On examination at his arrival, he was alert with reduced concentration and incoherent thoughts. The blood pressure was 181/87 mmHg and other vital signs were normal. Neurological findings showed slight dysarthria and slow movements but no other abnormalities. Laboratory data showed increased serum creatinine and potassium presumably for a session of periodical hemodialysis but normal sodium concentration. His cerebrospinal fluid examination was normal. We treated him by hemodialysis. Diagnosis of PRES was most likely because of the clinical features and the MRI findings. His symptoms had disappeared immediately and completely after we controlled high blood pressure. MRI on 13 days after admission showed the improvement of the abnormal findings. Although the pathophysiology of PRES is incompletely understood, renal failure was known as one of the risk factors. A relative lack of sympathetic innervation of posterior circulation could not protect the area when severe hypertension makes auto-regulatory control collapsed. However, PRES of the brainstem is uncommon although the posterior circulation involves it. Because control of his hypertension was not appropriate in the outpatient settings before this event, it could have contributed to the recurrence in this patient.