The Japanese Society of Internal Medicine Acta Medica Okayama 0918-2918 61 12 2022 Adult Scurvy Presenting with Painful Purpura on the Legs 1913 1916 EN Nayu Tamura Center for Graduate Medical Education, Okayama University Hospital Takafumi Obara Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University Taihei Yamada Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University Tsuyoshi Nojima Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University Shunsuke Nakamura Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University Yasuhiro Koide Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University Makoto Takaoka Department of Emergency, Steel Memorial Hirohata Hospital Hiromichi Naito Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University Atsunori Nakao Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University Prolonged vitamin C deficiency can result in numerous metabolic abnormalities like impaired tissue repair and defective collagen synthesis. This case report describes a middle-age Japanese man presenting painful purpura on his lower limbs, severe anemia, and altered consciousness. The patient had been eating a selective diet lacking in vegetables and fruits since childhood. A serum analysis demonstrated a low level of vitamin C. The patient was treated with vitamin supplementation and psychological intervention. Scurvy is an underconsidered illness with a favorable prognosis if diagnosed early while it is still sporadically encountered in some patients with malabsorption or malnutrition even in modern times. No potential conflict of interest relevant to this article was reported.

Elsevier Ltd on behalf of IJS Publishing Group Ltd. Acta Medica Okayama 2210-2612 88 2021 The diagnosis of delayed expanding traumatic pseudoaneurysm of thoracic aorta caused by self-inflicted penetrating injury with crossbow bolt: A case report 106474 EN Shunsuke Nakamura Department of Emergency, Critical Care and Disaster Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences Taihei Yamada Department of Traumatology and Emergency Intensive Care Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences Hiromichi Naito Department of Emergency, Critical Care and Disaster Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences Naoya Sakoda Department of Cardiovascular Surgery, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences Atsunori Nakao Department of Emergency, Critical Care and Disaster Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences Introduction and importance: Penetrating chest trauma caused by a crossbow bolt is very rare. Herein, we report a successfully treated patient who attempted suicide by directing a crossbow to the chest cavity and developed an expanding pseudoaneurysm of the thoracic aorta during eight-day follow up. <br> Case presentation: A 51-year-old male was admitted to the emergency department after firing a crossbow bolt twice into his left chest. At admission, the patient was hemodynamically stable and maintaining oxygenation. The bolt had already been removed from the body. Contrast-enhanced computed tomography (CT) revealed a cavity pseudoaneurysm 2.5 mm in size in the aortic arch. Three-dimensional reconstruction of the CT demonstrated wound tracts showing probable damage by the bolt. The patient was admitted to the emergency department for careful observation and transferred to the psychiatric ward on day two. Follow-up contrast-enhanced CT on day eight demonstrated rapid expansion of the pseudoaneurysm from 2.5 mm to 4.0 mm in size. We performed thoracic endovascular aortic repair (TEVAR) on day 13. The patient was uneventfully discharged on the 20th hospital day. <br> Clinical discussion: Emergency physicians should be aware that damage to the surrounding tissue may be accompanied by delayed expansion of an aortic pseudoaneurysm, even if the bolts do not cause direct aortic wall injury. <br> Conclusion: This case suggests that understanding the injury mechanism, confirming the tract of the bolts, and carefully exploring traumatic pseudoaneurysm can lead to a less invasive operation due to early detection. No potential conflict of interest relevant to this article was reported.

BMC Acta Medica Okayama 1471-227X 21 1 2021 Association between emergency medical service transport time and survival in patients with traumatic cardiac arrest: a Nationwide retrospective observational study 104 EN Hiromichi Naito Department of Emergency, Critical Care, and Disaster Medicine, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine Tetsuya Yumoto Department of Emergency, Critical Care, and Disaster Medicine, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine Takashi Yorifuji Dentistry and Pharmaceutical Sciences, Department of Epidemiology, Okayama University Graduate School of Medicine Tsuyoshi Nojima Department of Emergency, Critical Care, and Disaster Medicine, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine Hirotsugu Yamamoto Department of Emergency, Critical Care, and Disaster Medicine, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine Taihei Yamada Department of Emergency, Critical Care, and Disaster Medicine, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine Kohei Tsukahara Department of Emergency, Critical Care, and Disaster Medicine, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine Mototaka Inaba Department of Emergency, Critical Care, and Disaster Medicine, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine Takeshi Nishimura Department of Emergency, Critical Care, and Disaster Medicine, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine Takenori Uehara Department of Emergency, Critical Care, and Disaster Medicine, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine Atsunori Nakao Department of Emergency, Critical Care, and Disaster Medicine, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine Background <br> Patients with traumatic cardiac arrest (TCA) are known to have poor prognoses. In 2003, the joint committee of the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma proposed stopping unsuccessful cardiopulmonary resuscitation (CPR) sustained for > 15 min after TCA. However, in 2013, a specific time-limit for terminating resuscitation was dropped, due to the lack of conclusive studies or data. We aimed to define the association between emergency medical services transport time and survival to demonstrate the survival curve of TCA. <br> Methods <br> A retrospective review of the Japan Trauma Data Bank. Inclusion criteria were age >= 16, at least one trauma with Abbreviated Injury Scale score (AIS) >= 3, and CPR performed in a prehospital setting. Exclusion criteria were burn injury, AIS score of 6 in any region, and missing data. Estimated survival rate and risk ratio for survival were analyzed according to transport time for all patients. Analysis was also performed separately on patients with sustained TCA at arrival. <br> Results <br> Of 292,027 patients in the database, 5336 were included in the study with 4141 sustained TCA. Their median age was 53 years (interquartile range (IQR) 36-70), and 67.2% were male. Their median Injury Severity Score was 29 (IQR 22-41), and median transport time was 11 min (IQR 6-17). Overall survival after TCA was 4.5%; however, survival of patients with sustained TCA at arrival was only 1.2%. The estimated survival rate and risk ratio for sustained TCA rapidly decreased after 15 min of transport time, with estimated survival falling below 1%. <br> Conclusion <br> The chances of survival for sustained TCA declined rapidly while the patient is transported with CPR support. Time should be one reasonable factor for considering termination of resuscitation in patients with sustained TCA, although clinical signs of life, and type and severity of trauma should be taken into account clinically. No potential conflict of interest relevant to this article was reported.

Wiley Acta Medica Okayama 2688-1152 1 5 2020 Glycogenic hepatopathy following attempted suicide by long-acting insulin overdose in patient with type 1 diabetes 1097 1100 EN Noritomo Fujisaki Department of Emergency, Critical Care and Disaster Medicine,Okayama University Yoshinori Kosaki Department of Emergency, Critical Care and Disaster Medicine,Okayama University Tsuyoshi Nojima Department of Emergency, Critical Care and Disaster Medicine,Okayama University Taiki Higaki Department of Emergency, Critical Care and Disaster Medicine,Okayama University Taihei Yamada Department of Emergency, Critical Care and Disaster Medicine,Okayama University Hitoshi Koga Department of Emergency Medicine, StMaria Hospital Akira Gochi Department of Surgery, Ibara City Hospital Hiromichi Naito Department of Emergency, Critical Care and Disaster Medicine,Okayama University Atsunori Nakao Department of Emergency, Critical Care and Disaster Medicine,Okayama University Patients with poorly controlled insulin-dependent type 1 or type 2 diabetes rarely present with glycogenic hepatopathy, which is characterized by hepatomegaly and liver enzyme abnormalities. Glycogenic hepatopathy occurs as a consequence of excessive accumulation of glycogen in hepatocytes caused by insulin. We report a young male patient with type 1 diabetes mellitus who developed glycogenic hepatopathy following a suicide attempt by insulin overdose via subcutaneous injection. The patient's medication/nutrition compliance and adherence to insulin were poorly controlled due to comorbid schizophrenia. Our patient required a large amount of continuous glucose to maintain euglycemia for persistent intractable hypoglycemia induced by overdose of long-acting insulin. On admission day 4, the patient presented elevated transaminases, hepatomegaly, and lactic acidosis. Computed tomography revealed swollen liver parenchyma with a diffusely high absorption. The patient gradually recovered without any medical intervention except for adequate control of blood sugar and was moved to a psychiatric ward on day 8 for schizophrenia management. This report may help emergency physicians be aware of the common symptoms, clinical course, and pathophysiology of glycogenic hepatopathy. Doctors should include glycogenic hepatopathy in the differential diagnosis of abnormal liver enzymes and hepatomegaly for those with poorly controlled insulin-dependent diabetes mellitus or unstable blood sugar levels due to insulin overdose like our patient. No potential conflict of interest relevant to this article was reported.

Okayama University Medical School Acta Medica Okayama 0386-300X 74 6 2020 Delay in Emergency Medical Service Transportation Responsiveness during the COVID-19 Pandemic in a Minimally Affected Region 513 520 EN Kohei Ageta Department of Emergency, Critical Care and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences Hiromichi Naito Department of Emergency, Critical Care and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences Takashi Yorifuji Department of Epidemiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences Takafumi Obara Department of Emergency, Critical Care and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences Tsuyoshi Nojima Department of Emergency, Critical Care and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences Taihei Yamada Department of Emergency, Critical Care and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences Kohei Tsukahara Department of Emergency, Critical Care and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences Hiromasa Yakushiji Department of Emergency, Critical Care and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences Atsunori Nakao Department of Emergency, Critical Care and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences Original Article 10.18926/AMO/61210 Few studies have investigated the influence of the Coronavirus Disease 2019 (COVID-19) pandemic on emer-gency medical service (EMS) systems, especially in areas less affected or unaffected by COVID-19. In this study, we investigated changes in prehospital EMS activity and transport times during the COVID-19 pandemic. All patients transported by EMS in the city of Okayama from March–May 2019 or March–May 2020 were included. Interfacility transports were excluded. The primary outcome was the time from a patient�fs first emergency call until hospital arrival (total prehospital time). Secondary outcomes included three segments of total prehospital time: the response time, on-scene time, and transportation time. Total prehospital time and the durations of each segment were compared between corresponding months in 2020 (COVID19-affected) and 2019 (control). The results showed that total prehospital times in April 2020 were significantly higher than those in 2019 (33.8 �} 11.6 vs. 32.2 �} 10.8 min, p < 0.001). Increases in total prehospital time were caused by longer response time (9.3 �} 3.8 vs. 8.7 �} 3.7 min, p < 0.001) and on-scene time (14.4 �} 7.9 vs. 13.5 �} 6.2min, p < 0.001). The COVID-19 pandemic was thus shown to affect EMS and delayed arrival/response even in a minimally affected region. A system to minimize transportation delays should be developed for emerging pandemics. No potential conflict of interest relevant to this article was reported.

Wiley Acta Medica Okayama 2052-8817 7 1 2020 Therapeutic strategies for ischemia reperfusion injury in emergency medicine e501 EN Hiromichi Naitou Department of Emergency, Critical Care and Disaster Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences Tsuyoshi Nojima Department of Emergency, Critical Care and Disaster Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences Noritomo Fujisaki Department of Emergency, Critical Care and Disaster Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences Kohei Tsukahara Department of Emergency, Critical Care and Disaster Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences Hirotsugu Yamamoto Department of Emergency, Critical Care and Disaster Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences Taihei Yamada Department of Emergency, Critical Care and Disaster Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences Toshiyuki Aokage Department of Emergency, Critical Care and Disaster Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences Tetsuya Yumoto Department of Emergency, Critical Care and Disaster Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences Takaaki Osako Department of Emergency, Critical Care and Disaster Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences Atsunori Nakao Department of Emergency, Critical Care and Disaster Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences Ischemia reperfusion (IR) injury occurs when blood supply, perfusion, and concomitant reoxygenation is restored to an organ or area following an initial poor blood supply after a critical time period. Ischemia reperfusion injury contributes to mortality and morbidity in many pathological conditions in emergency medicine clinical practice, including trauma, ischemic stroke, myocardial infarction, and post-cardiac arrest syndrome. The process of IR is multifactorial, and its pathogenesis involves several mechanisms. Reactive oxygen species are considered key molecules in reperfusion injury due to their potent oxidizing and reducing effects that directly damage cellular membranes by lipid peroxidation. In general, IR injury to an individual organ causes various pro-inflammatory mediators to be released, which could then induce inflammation in remote organs, thereby possibly advancing the dysfunction of multiple organs. In this review, we summarize IR injury in emergency medicine. Potential therapies include pharmacological treatment, ischemic preconditioning, and the use of medical gases or vitamin therapy, which could significantly help experts develop strategies to inhibit IR injury. No potential conflict of interest relevant to this article was reported.

Okayama University Medical School Acta Medica Okayama 0386-300X 74 4 2020 Hospital Evacuation Assistance from Public and Private Resources: Lessons Learned from the 2018 Western Japan Floods 359 364 EN Mototaka Inaba Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences Hiromichi Naito Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences Tomoyoshi Muramatsu Mabi Memorial Hospital Taihei Yamada Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences Taizo Sakata Peace Winds Japan Atsunori Nakao Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences Case Report 10.18926/AMO/60375 During major flooding in June/July 2018, the Mabi Memorial Hospital in Kurashiki, Okayama, Japan was flooded and patients were stranded in the hospital. Peace Winds Japan, a non-governmental organization, collaborated with the Japanese Disaster Medical Assistance Team and Self-Defense Force Public to transport 8 critical patients from the hospital by helicopter. Ultimately, 54 patients and hospital staff members were safely evacuated. The evacuation was accomplished without any casualties, despite the severe conditions. Public and private organizations can work together and continue to seek ways to collaborate and cooperate in disaster settings. No potential conflict of interest relevant to this article was reported.

Elsevier Acta Medica Okayama 22102612 65 2019 A case of spontaneous mesenteric hematoma successfully diagnosed and treated with aggressive imaging 124 126 EN Shunsuke Nakamura Department of Emergency, Critical Care and Disaster Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences Taihei Yamada Department of Emergency, Critical Care and Disaster Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences Tsuyoshi Nojima Department of Emergency, Critical Care and Disaster Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences Hiromichi Naitou Department of Emergency, Critical Care and Disaster Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences Hitoshi Koga Department of Emergency Medicine, St. Mary�fs Hospital Hisashi Yamashita Department of Emergency Medicine, St. Mary�fs Hospital Akira Gochi Department of Surgery, Ibara City Hospital Atsunori Nakao Department of Emergency, Critical Care and Disaster Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences Introduction: Spontaneous mesenteric hematoma is an uncommon syndrome triggered by bleeding localized in the mesenteric vascular tree of a bowel segment for no apparent underlying reason. We herein report a surgical patient with an extremely rapidly growing spontaneous mesenteric hematoma that we successfully diagnosed using careful radiologic examination.<br/> Presentation of case: A 56-year-old old male presenting sudden onset lower abdominal pain was referred to our emergency department. At the time of admission, his physical examination revealed stable vital signs without radiological abnormality. On the following day, the patient suddenly presented hypotension, tachycardia, and increased abdominal pain. Contrast-enhanced computed tomography examination showed a mass with both high- and low-density areas with a 130 mm maximum diameter bordering the transverse colon. Since interventional radiologists were not available, we decided to perform emergency exploratory laparotomy. On laparotomy, a 13 �~ 8 cm hematoma was found in the mesentery of the transverse colon. As bleeding was noted from the branches of the middle colic artery and gastrocolic artery, these responsible vessels were ligated. The patient was finally given the diagnosis of spontaneous mesenteric hematoma.<br/> Discussion and conclusion: The present case, initially diagnosed as enterocolitis, suddenly manifested hypovolemic shock. Close monitoring for any signs of further deterioration, as well as aggressive imaging diagnosis, enabled us to avoid delays in treatment. Early diagnosis and treatment of mesenteric hematomas are essential to prevent them from rupturing and triggering life-threatening adverse events. No potential conflict of interest relevant to this article was reported.