Masahiro Wakasugi

Valacyclovir neurotoxicity: clinical experience and review of the literature

Valacyclovir (VACV) is used increasingly to treat herpes zoster, although neuropsychiatric symptoms [VACV neurotoxicity (VAN) or acyclovir neurotoxicity], may accompany use of this drug. To promote awareness of this rare condition, we describe here two clinical cases of VAN we previously reported and review 20 cases from the literature. In all cases, chronic or acute renal failure preceded VAN. The symptoms of VAN varied, but disturbances of consciousness and hallucination occurred most commonly. When acute renal failure was due to the drug, recovery from both the disturbance of consciousness and renal failure followed within several days after discontinuation of VACV. Early recognition and diagnosis will ensure effective treatment of VAN.

Development of the New Coma Scale: Emergency Coma Scale (ECS)

Coma scale is fundamental to assess the patients of disturbed consciousness. Without using coma scales, it is hard to evaluate and discuss about not faced patients. Objective indicator of impaired consciousness is vital to compare treatment results of coma patients with other institution.

Prognostic significance of disseminated intravascular coagulation in patients with heat stroke in a nationwide registry

Purpose: Heat stroke (HS) induces disseminated intravascular coagulation (DIC); however, the prognostic significance of DIC in patients with HS has not yet been fully assessed in large populations. The aim of this study was to examine the prognostic significance of DIC in patients with HS using a nationwide registry. Materials and methods: Data regarding HS were obtained and analyzed from three prospective, observational, multicenter HS registries (HSRs): 2010, 2012, and 2014. Univariate and multivariate analyses were performed to identify independent predictors of hospital death. DIC was diagnosed according to the Japanese Association for Acute Medicine (JAAM) diagnostic criteria, with a total score ≥ 4 implying a DIC diagnosis. Results: In total, 705 (median age, 68 years; 501 men) were included in this study. Hospital mortality was 7.1% (50 patients). Multiple regression analysis revealed that hospital mortality was significantly associated with presence of DIC (odds ratio [OR], 2.16; 95% confidence interval [CI], 1.09–4.27; p = 0.028). Mortality worsened as the DIC score increased, and increased remarkably to approximately 10% when the DIC score was 2. Conclusions: Presence of DIC was an independent prognostic factor of hospital mortality in patients with HS. Hematological dysfunction represents potential target for specific therapies in HS. HighlightsPresence of DIC was an independent prognostic factor in HS.Mortality increased remarkably to approximately 10% even at a DIC score of 2.AT‐III levels on admission in non‐survivors were significantly lower than those of survivors.

Evaluation of a Novel Classification of Heat-Related Illnesses: A Multicentre Observational Study (Heat Stroke STUDY 2012)

The Japanese Association for Acute Medicine Committee recently proposed a novel classification system for the severity of heat-related illnesses. The illnesses are simply classified into three stages based on symptoms and management or treatment. Stages I, II, and III broadly correspond to heat cramp and syncope, heat exhaustion, and heat stroke, respectively. Our objective was to examine whether this novel severity classification is useful in the diagnosis by healthcare professionals of patients with severe heat-related illness and organ failure. A nationwide surveillance study of heat-related illnesses was conducted between 1 June and 30 September 2012, at emergency departments in Japan. Among the 2130 patients who attended 102 emergency departments, the severity of their heat-related illness was recorded for 1799 patients, who were included in this study. In the patients with heat cramp and syncope or heat exhaustion (but not heat stroke), the blood test data (alanine aminotransferase, creatinine, blood urea nitrogen, and platelet counts) for those classified as Stage III were significantly higher than those of patients classified as Stage I or II. There were no deaths among the patients classified as Stage I. This novel classification may avoid underestimating the severity of heat-related illness.

Evaluation of the accuracy of the Emergency Coma Scale: E-COMET STEP II.

In 2002, Ohta and the Emergency Coma Scale Society began the development of a new coma scale, the Emergency Coma Scale (ECS), and established it the following year (Table 1) [1-3]. The ECS combines the advantages of the Glasgow Coma Scale (GCS) and the Japan Coma Scale (JCS). We predict that the ECS could achieve higher agreement and accuracy and has a sufficiently simple structure to be accepted by comedicals including nurses and paramedics. To prove these hypotheses, we designed a multicenter study called the “ECS Co-Operative Multi-center Evaluation Trial: E-COMET” [4]. E-COMET consists of 2 series of trials, STEP I and STEP II. We have already reported on STEP I in 2011, in which the ECS, of all 3 scales, showed the highest agreement of scores among multiple raters [5,6]. As a next step, we attempted to prove the accuracy of the ECS on STEP II. Medical students in the fourth and fifth grade at theUniversity of Toyama participated in this trial. They attended lectures about the evaluationmethods of the ECS, GCS, and JCSwithin their training period at the emergency department (ED) in our hospital. Participants watched videos of the simulated patients with consciousness disturbance acted by ED physicians at Toyama University Hospital. We prepared 3 cases of different severities (Table 2). Each case had a correct scoring response for each of the 3 coma scales. After finishing the video, the participants evaluated the conscious level of each case by 3 scales, and they input these data from the ECS Web site and these data were directory transferred to our database at the Department of Crisis Medicine, University of Toyama. Data were analyzed with the statistical software Dr. SPSS II for Windows (SPSS, Inc, Chicago, IL). We calculated the weighted mean percentage of correct answers for the 3 coma scales and compared these results. We adopted the Wilcoxon signed rank test as a test of average difference [7]. Data from 88 participants (54 data in the fourth and 34 data in the fifth grade students) were included in our statistical analysis. Among all participants, the weighted mean percentage of correct answers showed a significantly higher score for the ECS (86.62 ± 14.35) (Wilcoxon signed rank test: JCS-ECS P = .01) than for the other 2 scales (Table 3). The weighted mean percentages of correct answers of the fourth grade students were significantly lower than those of the fifth grade students for all 3 scales. The tendency was particularly significant for the GCS. At our university, medical students usually start clinical training at the hospital in the fifth grade, when they examine patients for the first time, and their scores were higher than fourth grades. It seems that, to truly grasp any evaluation method, it is necessary to experience actual patients with consciousness disturbance. Based on this assumption, Okudera et al [8] developed a simulation training course, the Immediate Stroke Life Support (ISLS) course, which aims to teach themanagement of patients with cerebrovascular diseases at emergency settings in Japan. The course is intended for all medical professionals and is now expanding throughout Japan. This course uses the ECS as a tool to evaluate the consciousness level of patients with stroke. This study elucidated that the ECS evaluation method is easy to understand for beginners of evaluation by coma scales. We think that it may be effective to introduce the ECS to medical education, not only for nurses, medical students, and paramedics but also for citizens. If it is too difficult for citizens to fully understand the evaluation method of the ECS, the 3 major categories of the ECS are still very useful. The ECS is divided in 3major categories, and they are defined solely according to the intensity of the stimulation which can wake patients and showed a strong correlation with the outcome of the patients with stroke and traumatic brain injury in our previous analyses [5,6]. The need for rapid and accurate diagnosis and treatment of patients with stroke and traumatic brain injury has been increasingly recognized in attempts to improve the quality of prehospital and inhospitalmedical services. Indeed, quick, accurate diagnosis and treatment often determine the outcomes of these patients. We think that the unification of the coma scale among multiprofessionals may improve the efficiency in diagnosis and medical treatment and lead to improved patient outcomes. From the results of both E-COMET STEP I and STEP II, we conclude that the ECS is extremely useful enough to spread widely in the treatment of neurologic emergencies. We think that it is necessary to reassess the results for all raters after collecting additional data from physicians and nurses.