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Publisher: John Wiley and Sons   (Total: 1589 journals)

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Showing 1 - 200 of 1589 Journals sorted alphabetically
Abacus     Hybrid Journal   (Followers: 12, SJR: 0.48, h-index: 22)
About Campus     Hybrid Journal   (Followers: 5)
Academic Emergency Medicine     Hybrid Journal   (Followers: 65, SJR: 1.385, h-index: 91)
Accounting & Finance     Hybrid Journal   (Followers: 48, SJR: 0.547, h-index: 30)
ACEP NOW     Free   (Followers: 1)
Acta Anaesthesiologica Scandinavica     Hybrid Journal   (Followers: 53, SJR: 1.02, h-index: 88)
Acta Archaeologica     Hybrid Journal   (Followers: 168, SJR: 0.101, h-index: 9)
Acta Geologica Sinica (English Edition)     Hybrid Journal   (Followers: 3, SJR: 0.552, h-index: 41)
Acta Neurologica Scandinavica     Hybrid Journal   (Followers: 5, SJR: 1.203, h-index: 74)
Acta Obstetricia et Gynecologica Scandinavica     Hybrid Journal   (Followers: 15, SJR: 1.197, h-index: 81)
Acta Ophthalmologica     Hybrid Journal   (Followers: 6, SJR: 0.112, h-index: 1)
Acta Paediatrica     Hybrid Journal   (Followers: 56, SJR: 0.794, h-index: 88)
Acta Physiologica     Hybrid Journal   (Followers: 6, SJR: 1.69, h-index: 88)
Acta Polymerica     Hybrid Journal   (Followers: 9)
Acta Psychiatrica Scandinavica     Hybrid Journal   (Followers: 37, SJR: 2.518, h-index: 113)
Acta Zoologica     Hybrid Journal   (Followers: 7, SJR: 0.459, h-index: 29)
Acute Medicine & Surgery     Hybrid Journal   (Followers: 5)
Addiction     Hybrid Journal   (Followers: 36, SJR: 2.086, h-index: 143)
Addiction Biology     Hybrid Journal   (Followers: 14, SJR: 2.091, h-index: 57)
Adultspan J.     Hybrid Journal   (SJR: 0.127, h-index: 4)
Advanced Energy Materials     Hybrid Journal   (Followers: 26, SJR: 6.411, h-index: 86)
Advanced Engineering Materials     Hybrid Journal   (Followers: 26, SJR: 0.81, h-index: 81)
Advanced Functional Materials     Hybrid Journal   (Followers: 51, SJR: 5.21, h-index: 203)
Advanced Healthcare Materials     Hybrid Journal   (Followers: 14, SJR: 0.232, h-index: 7)
Advanced Materials     Hybrid Journal   (Followers: 295, SJR: 9.021, h-index: 345)
Advanced Materials Interfaces     Hybrid Journal   (Followers: 6, SJR: 1.177, h-index: 10)
Advanced Optical Materials     Hybrid Journal   (Followers: 7, SJR: 2.488, h-index: 21)
Advanced Science     Open Access   (Followers: 5)
Advanced Synthesis & Catalysis     Hybrid Journal   (Followers: 17, SJR: 2.729, h-index: 121)
Advances in Polymer Technology     Hybrid Journal   (Followers: 13, SJR: 0.344, h-index: 31)
Africa Confidential     Hybrid Journal   (Followers: 21)
Africa Research Bulletin: Economic, Financial and Technical Series     Hybrid Journal   (Followers: 13)
Africa Research Bulletin: Political, Social and Cultural Series     Hybrid Journal   (Followers: 11)
African Development Review     Hybrid Journal   (Followers: 33, SJR: 0.275, h-index: 17)
African J. of Ecology     Hybrid Journal   (Followers: 16, SJR: 0.477, h-index: 39)
Aggressive Behavior     Hybrid Journal   (Followers: 15, SJR: 1.391, h-index: 66)
Aging Cell     Open Access   (Followers: 11, SJR: 4.374, h-index: 95)
Agribusiness : an Intl. J.     Hybrid Journal   (Followers: 3, SJR: 0.627, h-index: 14)
Agricultural and Forest Entomology     Hybrid Journal   (Followers: 16, SJR: 0.925, h-index: 43)
Agricultural Economics     Hybrid Journal   (Followers: 45, SJR: 1.099, h-index: 51)
AIChE J.     Hybrid Journal   (Followers: 32, SJR: 1.122, h-index: 120)
Alcoholism and Drug Abuse Weekly     Hybrid Journal   (Followers: 7)
Alcoholism Clinical and Experimental Research     Hybrid Journal   (Followers: 7, SJR: 1.416, h-index: 125)
Alimentary Pharmacology & Therapeutics     Hybrid Journal   (Followers: 33, SJR: 2.833, h-index: 138)
Alimentary Pharmacology & Therapeutics Symposium Series     Hybrid Journal   (Followers: 3)
Allergy     Hybrid Journal   (Followers: 51, SJR: 3.048, h-index: 129)
Alternatives to the High Cost of Litigation     Hybrid Journal   (Followers: 3)
American Anthropologist     Hybrid Journal   (Followers: 152, SJR: 0.951, h-index: 61)
American Business Law J.     Hybrid Journal   (Followers: 24, SJR: 0.205, h-index: 17)
American Ethnologist     Hybrid Journal   (Followers: 93, SJR: 2.325, h-index: 51)
American J. of Economics and Sociology     Hybrid Journal   (Followers: 29, SJR: 0.211, h-index: 26)
American J. of Hematology     Hybrid Journal   (Followers: 35, SJR: 1.761, h-index: 77)
American J. of Human Biology     Hybrid Journal   (Followers: 13, SJR: 1.018, h-index: 58)
American J. of Industrial Medicine     Hybrid Journal   (Followers: 16, SJR: 0.993, h-index: 85)
American J. of Medical Genetics Part A     Hybrid Journal   (Followers: 16, SJR: 1.115, h-index: 61)
American J. of Medical Genetics Part B: Neuropsychiatric Genetics     Hybrid Journal   (Followers: 4, SJR: 1.771, h-index: 107)
American J. of Medical Genetics Part C: Seminars in Medical Genetics     Partially Free   (Followers: 6, SJR: 2.315, h-index: 79)
American J. of Physical Anthropology     Hybrid Journal   (Followers: 37, SJR: 1.41, h-index: 88)
American J. of Political Science     Hybrid Journal   (Followers: 290, SJR: 5.101, h-index: 114)
American J. of Primatology     Hybrid Journal   (Followers: 16, SJR: 1.197, h-index: 63)
American J. of Reproductive Immunology     Hybrid Journal   (Followers: 3, SJR: 1.347, h-index: 75)
American J. of Transplantation     Hybrid Journal   (Followers: 18, SJR: 2.792, h-index: 140)
American J. on Addictions     Hybrid Journal   (Followers: 9, SJR: 0.843, h-index: 57)
Anaesthesia     Hybrid Journal   (Followers: 138, SJR: 1.404, h-index: 88)
Analyses of Social Issues and Public Policy     Hybrid Journal   (Followers: 9, SJR: 0.397, h-index: 18)
Analytic Philosophy     Hybrid Journal   (Followers: 20)
Anatomia, Histologia, Embryologia: J. of Veterinary Medicine Series C     Hybrid Journal   (Followers: 3, SJR: 0.295, h-index: 27)
Anatomical Sciences Education     Hybrid Journal   (Followers: 1, SJR: 0.633, h-index: 24)
Andrologia     Hybrid Journal   (Followers: 2, SJR: 0.528, h-index: 45)
Andrology     Hybrid Journal   (Followers: 2, SJR: 0.979, h-index: 14)
Angewandte Chemie     Hybrid Journal   (Followers: 179)
Angewandte Chemie Intl. Edition     Hybrid Journal   (Followers: 229, SJR: 6.229, h-index: 397)
Animal Conservation     Hybrid Journal   (Followers: 41, SJR: 1.576, h-index: 62)
Animal Genetics     Hybrid Journal   (Followers: 8, SJR: 0.957, h-index: 67)
Animal Science J.     Hybrid Journal   (Followers: 6, SJR: 0.569, h-index: 24)
Annalen der Physik     Hybrid Journal   (Followers: 5, SJR: 1.46, h-index: 40)
Annals of Anthropological Practice     Partially Free   (Followers: 2, SJR: 0.187, h-index: 5)
Annals of Applied Biology     Hybrid Journal   (Followers: 7, SJR: 0.816, h-index: 56)
Annals of Clinical and Translational Neurology     Open Access   (Followers: 1)
Annals of Human Genetics     Hybrid Journal   (Followers: 9, SJR: 1.191, h-index: 67)
Annals of Neurology     Hybrid Journal   (Followers: 48, SJR: 5.584, h-index: 241)
Annals of Noninvasive Electrocardiology     Hybrid Journal   (Followers: 1, SJR: 0.531, h-index: 38)
Annals of Public and Cooperative Economics     Hybrid Journal   (Followers: 8, SJR: 0.336, h-index: 23)
Annals of the New York Academy of Sciences     Hybrid Journal   (Followers: 5, SJR: 2.389, h-index: 189)
Annual Bulletin of Historical Literature     Hybrid Journal   (Followers: 13)
Annual Review of Information Science and Technology     Hybrid Journal   (Followers: 14)
Anthropology & Education Quarterly     Hybrid Journal   (Followers: 25, SJR: 0.72, h-index: 31)
Anthropology & Humanism     Hybrid Journal   (Followers: 17, SJR: 0.137, h-index: 3)
Anthropology News     Hybrid Journal   (Followers: 15)
Anthropology of Consciousness     Hybrid Journal   (Followers: 11, SJR: 0.172, h-index: 5)
Anthropology of Work Review     Hybrid Journal   (Followers: 11, SJR: 0.256, h-index: 5)
Anthropology Today     Hybrid Journal   (Followers: 91, SJR: 0.545, h-index: 15)
Antipode     Hybrid Journal   (Followers: 50, SJR: 2.212, h-index: 69)
Anz J. of Surgery     Hybrid Journal   (Followers: 8, SJR: 0.432, h-index: 59)
Anzeiger für Schädlingskunde     Hybrid Journal   (Followers: 1)
Apmis     Hybrid Journal   (Followers: 1, SJR: 0.855, h-index: 73)
Applied Cognitive Psychology     Hybrid Journal   (Followers: 70, SJR: 0.754, h-index: 69)
Applied Organometallic Chemistry     Hybrid Journal   (Followers: 7, SJR: 0.632, h-index: 58)
Applied Psychology     Hybrid Journal   (Followers: 209, SJR: 1.023, h-index: 64)
Applied Psychology: Health and Well-Being     Hybrid Journal   (Followers: 50, SJR: 0.868, h-index: 13)
Applied Stochastic Models in Business and Industry     Hybrid Journal   (Followers: 5, SJR: 0.613, h-index: 24)
Aquaculture Nutrition     Hybrid Journal   (Followers: 14, SJR: 1.025, h-index: 55)
Aquaculture Research     Hybrid Journal   (Followers: 32, SJR: 0.807, h-index: 60)
Aquatic Conservation Marine and Freshwater Ecosystems     Hybrid Journal   (Followers: 36, SJR: 1.047, h-index: 57)
Arabian Archaeology and Epigraphy     Hybrid Journal   (Followers: 11, SJR: 0.453, h-index: 11)
Archaeological Prospection     Hybrid Journal   (Followers: 12, SJR: 0.922, h-index: 21)
Archaeology in Oceania     Hybrid Journal   (Followers: 13, SJR: 0.745, h-index: 18)
Archaeometry     Hybrid Journal   (Followers: 29, SJR: 0.809, h-index: 48)
Archeological Papers of The American Anthropological Association     Hybrid Journal   (Followers: 15, SJR: 0.156, h-index: 2)
Architectural Design     Hybrid Journal   (Followers: 26, SJR: 0.261, h-index: 9)
Archiv der Pharmazie     Hybrid Journal   (Followers: 3, SJR: 0.628, h-index: 43)
Archives of Drug Information     Hybrid Journal   (Followers: 5)
Archives of Insect Biochemistry and Physiology     Hybrid Journal   (SJR: 0.768, h-index: 54)
Area     Hybrid Journal   (Followers: 13, SJR: 0.938, h-index: 57)
Art History     Hybrid Journal   (Followers: 274, SJR: 0.153, h-index: 13)
Arthritis & Rheumatology     Hybrid Journal   (Followers: 54, SJR: 1.984, h-index: 20)
Arthritis Care & Research     Hybrid Journal   (Followers: 27, SJR: 2.256, h-index: 114)
Artificial Organs     Hybrid Journal   (Followers: 1, SJR: 0.872, h-index: 60)
ASHE Higher Education Reports     Hybrid Journal   (Followers: 15)
Asia & the Pacific Policy Studies     Open Access   (Followers: 16)
Asia Pacific J. of Human Resources     Hybrid Journal   (Followers: 326, SJR: 0.494, h-index: 19)
Asia Pacific Viewpoint     Hybrid Journal   (Followers: 1, SJR: 0.616, h-index: 26)
Asia-Pacific J. of Chemical Engineering     Hybrid Journal   (Followers: 8, SJR: 0.345, h-index: 20)
Asia-pacific J. of Clinical Oncology     Hybrid Journal   (Followers: 6, SJR: 0.554, h-index: 14)
Asia-Pacific J. of Financial Studies     Hybrid Journal   (SJR: 0.241, h-index: 7)
Asia-Pacific Psychiatry     Hybrid Journal   (Followers: 4, SJR: 0.377, h-index: 7)
Asian Economic J.     Hybrid Journal   (Followers: 8, SJR: 0.234, h-index: 21)
Asian Economic Policy Review     Hybrid Journal   (Followers: 4, SJR: 0.196, h-index: 12)
Asian J. of Control     Hybrid Journal   (SJR: 0.862, h-index: 34)
Asian J. of Endoscopic Surgery     Hybrid Journal   (Followers: 1, SJR: 0.394, h-index: 7)
Asian J. of Organic Chemistry     Hybrid Journal   (Followers: 6, SJR: 1.443, h-index: 19)
Asian J. of Social Psychology     Hybrid Journal   (Followers: 5, SJR: 0.665, h-index: 37)
Asian Politics and Policy     Hybrid Journal   (Followers: 12, SJR: 0.207, h-index: 7)
Asian Social Work and Policy Review     Hybrid Journal   (Followers: 5, SJR: 0.318, h-index: 5)
Asian-pacific Economic Literature     Hybrid Journal   (Followers: 5, SJR: 0.168, h-index: 15)
Assessment Update     Hybrid Journal   (Followers: 4)
Astronomische Nachrichten     Hybrid Journal   (Followers: 3, SJR: 0.701, h-index: 40)
Atmospheric Science Letters     Open Access   (Followers: 29, SJR: 1.332, h-index: 27)
Austral Ecology     Hybrid Journal   (Followers: 15, SJR: 1.095, h-index: 66)
Austral Entomology     Hybrid Journal   (Followers: 9, SJR: 0.524, h-index: 28)
Australasian J. of Dermatology     Hybrid Journal   (Followers: 8, SJR: 0.714, h-index: 40)
Australasian J. On Ageing     Hybrid Journal   (Followers: 6, SJR: 0.39, h-index: 22)
Australian & New Zealand J. of Statistics     Hybrid Journal   (Followers: 14, SJR: 0.275, h-index: 28)
Australian Accounting Review     Hybrid Journal   (Followers: 3, SJR: 0.709, h-index: 14)
Australian and New Zealand J. of Family Therapy (ANZJFT)     Hybrid Journal   (Followers: 3, SJR: 0.382, h-index: 12)
Australian and New Zealand J. of Obstetrics and Gynaecology     Hybrid Journal   (Followers: 47, SJR: 0.814, h-index: 49)
Australian and New Zealand J. of Public Health     Hybrid Journal   (Followers: 11, SJR: 0.82, h-index: 62)
Australian Dental J.     Hybrid Journal   (Followers: 6, SJR: 0.482, h-index: 46)
Australian Economic History Review     Hybrid Journal   (Followers: 6, SJR: 0.171, h-index: 12)
Australian Economic Papers     Hybrid Journal   (Followers: 31, SJR: 0.23, h-index: 9)
Australian Economic Review     Hybrid Journal   (Followers: 6, SJR: 0.357, h-index: 21)
Australian Endodontic J.     Hybrid Journal   (Followers: 3, SJR: 0.513, h-index: 24)
Australian J. of Agricultural and Resource Economics     Hybrid Journal   (Followers: 3, SJR: 0.765, h-index: 36)
Australian J. of Grape and Wine Research     Hybrid Journal   (Followers: 5, SJR: 0.879, h-index: 56)
Australian J. of Politics & History     Hybrid Journal   (Followers: 15, SJR: 0.203, h-index: 14)
Australian J. of Psychology     Hybrid Journal   (Followers: 18, SJR: 0.384, h-index: 30)
Australian J. of Public Administration     Hybrid Journal   (Followers: 419, SJR: 0.418, h-index: 29)
Australian J. of Rural Health     Hybrid Journal   (Followers: 5, SJR: 0.43, h-index: 34)
Australian Occupational Therapy J.     Hybrid Journal   (Followers: 72, SJR: 0.59, h-index: 29)
Australian Psychologist     Hybrid Journal   (Followers: 12, SJR: 0.331, h-index: 31)
Australian Veterinary J.     Hybrid Journal   (Followers: 23, SJR: 0.459, h-index: 45)
Autism Research     Hybrid Journal   (Followers: 36, SJR: 2.126, h-index: 39)
Autonomic & Autacoid Pharmacology     Hybrid Journal   (SJR: 0.371, h-index: 29)
Banks in Insurance Report     Hybrid Journal   (Followers: 1)
Basic & Clinical Pharmacology & Toxicology     Hybrid Journal   (Followers: 11, SJR: 0.539, h-index: 70)
Basic and Applied Pathology     Open Access   (Followers: 2, SJR: 0.113, h-index: 4)
Basin Research     Hybrid Journal   (Followers: 5, SJR: 1.54, h-index: 60)
Bauphysik     Hybrid Journal   (Followers: 2, SJR: 0.194, h-index: 5)
Bauregelliste A, Bauregelliste B Und Liste C     Hybrid Journal  
Bautechnik     Hybrid Journal   (Followers: 1, SJR: 0.321, h-index: 11)
Behavioral Interventions     Hybrid Journal   (Followers: 9, SJR: 0.297, h-index: 23)
Behavioral Sciences & the Law     Hybrid Journal   (Followers: 24, SJR: 0.736, h-index: 57)
Berichte Zur Wissenschaftsgeschichte     Hybrid Journal   (Followers: 10, SJR: 0.11, h-index: 5)
Beton- und Stahlbetonbau     Hybrid Journal   (Followers: 2, SJR: 0.493, h-index: 14)
Biochemistry and Molecular Biology Education     Hybrid Journal   (Followers: 6, SJR: 0.311, h-index: 26)
Bioelectromagnetics     Hybrid Journal   (Followers: 1, SJR: 0.568, h-index: 64)
Bioengineering & Translational Medicine     Open Access  
BioEssays     Hybrid Journal   (Followers: 10, SJR: 3.104, h-index: 155)
Bioethics     Hybrid Journal   (Followers: 14, SJR: 0.686, h-index: 39)
Biofuels, Bioproducts and Biorefining     Hybrid Journal   (Followers: 1, SJR: 1.725, h-index: 56)
Biological J. of the Linnean Society     Hybrid Journal   (Followers: 16, SJR: 1.172, h-index: 90)
Biological Reviews     Hybrid Journal   (Followers: 5, SJR: 6.469, h-index: 114)
Biologie in Unserer Zeit (Biuz)     Hybrid Journal   (Followers: 41, SJR: 0.12, h-index: 1)
Biology of the Cell     Full-text available via subscription   (Followers: 9, SJR: 1.812, h-index: 69)
Biomedical Chromatography     Hybrid Journal   (Followers: 6, SJR: 0.572, h-index: 49)
Biometrical J.     Hybrid Journal   (Followers: 5, SJR: 0.784, h-index: 44)
Biometrics     Hybrid Journal   (Followers: 37, SJR: 1.906, h-index: 96)
Biopharmaceutics and Drug Disposition     Hybrid Journal   (Followers: 10, SJR: 0.715, h-index: 44)
Biopolymers     Hybrid Journal   (Followers: 18, SJR: 1.199, h-index: 104)
Biotechnology and Applied Biochemistry     Hybrid Journal   (Followers: 44, SJR: 0.415, h-index: 55)
Biotechnology and Bioengineering     Hybrid Journal   (Followers: 152, SJR: 1.633, h-index: 146)
Biotechnology J.     Hybrid Journal   (Followers: 14, SJR: 1.185, h-index: 51)
Biotechnology Progress     Hybrid Journal   (Followers: 39, SJR: 0.736, h-index: 101)
Biotropica     Hybrid Journal   (Followers: 20, SJR: 1.374, h-index: 71)
Bipolar Disorders     Hybrid Journal   (Followers: 9, SJR: 2.592, h-index: 100)
Birth     Hybrid Journal   (Followers: 38, SJR: 0.763, h-index: 64)
Birth Defects Research Part A : Clinical and Molecular Teratology     Hybrid Journal   (Followers: 2, SJR: 0.727, h-index: 77)
Birth Defects Research Part B: Developmental and Reproductive Toxicology     Hybrid Journal   (Followers: 7, SJR: 0.468, h-index: 47)
Birth Defects Research Part C : Embryo Today : Reviews     Hybrid Journal   (SJR: 1.513, h-index: 55)
BJOG : An Intl. J. of Obstetrics and Gynaecology     Partially Free   (Followers: 247, SJR: 2.083, h-index: 125)

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Journal Cover Acute Medicine & Surgery
  [5 followers]  Follow
    
   Hybrid Journal Hybrid journal (It can contain Open Access articles)
   ISSN (Print) 2052-8817
   Published by John Wiley and Sons Homepage  [1589 journals]
  • Past, present, and future of Emergency General Surgery in the USA
    • Authors: Heather G. Lyu; Peter Najjar, Joaquim M. Havens
      Abstract: Emergency General Surgery (EGS) patients represent a unique group of acutely ill surgical patients at high risk for death and complications. Since the inception of EGS as a surgical subspecialty in the early 2000s, there have been significant developments to further define the scope of EGS as well as to advance data collection, performance measurement, and quality improvement. This includes defining the EGS cohort by diagnosis and procedure and by overall burden, benchmarking of EGS outcomes, and creation of quality improvement programs aimed at reducing the excess morbidity and mortality associated with EGS. Going forward there exists a need for a more modern approach to quality improvement. This may include the creation of an EGS data registry, the use of electronic medical records data, wearable device technology, and a focus on patient reported outcomes.This is a review of the scope and burden of emergency general surgery in the USA and a discussion of how to improve surgical outcomes in this population.
      PubDate: 2018-01-12T06:50:20.248251-05:
      DOI: 10.1002/ams2.327
       
  • A summary of the Japan septic disseminated intravascular coagulation study
    • Authors: Mineji Hayakawa; Kota Ono
      Abstract: Over the past few decades, the large, international, randomized controlled trials of anticoagulant therapies for patients with sepsis have not yielded any improvement in mortality rates. However, in Japan, anticoagulant therapies are administered for sepsis patients with disseminated intravascular coagulation (DIC), but not for sepsis patients without DIC. Furthermore, epidemiological data regarding sepsis in Japan are scarce. Therefore, a nationwide multicenter retrospective observational study, the Japan Septic Disseminated Intravascular Coagulation (JSEPTIC DIC) study, was undertaken. The JSEPTIC DIC study enrolled 42 intensive care units and included 3,195 patients with sepsis. The results of the JSEPTIC DIC study indicated the following: (i) anticoagulant therapy may be effective in sepsis-induced DIC patients at high risk for death, (ii) recombinant human soluble thrombomodulin administration and antithrombin supplementation are associated with survival benefits in patients with sepsis-induced DIC.A nationwide multicenter retrospective observational study, named the Japan Septic Disseminated Intravascular Coagulation (JSEPTIC DIC) study, was undertaken. The results of the JSEPTIC DIC study indicated that: (i) anticoagulant therapy may be effective in sepsis-induced DIC patients at high risk for death, (ii) recombinant human soluble thrombomodulin administration and antithrombin supplementation are associated with survival benefits in patients with sepsis-induced DIC
      PubDate: 2018-01-10T05:36:24.295256-05:
      DOI: 10.1002/ams2.326
       
  • Flunitrazepam overdose induces brilliant‐blue gastric fluid
    • Authors: Toshinobu Yamagishi; Akiko Akashi, Hiroshi Shimizu, Takuto Ishida, Takahiro Tanabe, Kazuhiro Sugiyama, Yuichi Hamabe
      PubDate: 2017-12-21T02:56:57.870988-05:
      DOI: 10.1002/ams2.325
       
  • Treatment of a patient with acute aortic dissection using extracorporeal
           cardiopulmonary resuscitation after an out‐of‐hospital cardiac arrest:
           a case report
    • Authors: Takahiro Yukawa; Kazuhiro Sugiyama, Kazuki Miyazaki, Takahiro Tanabe, Susumu Ishikawa, Yuichi Hamabe
      Abstract: CaseCirculatory support using veno‐arterial extracorporeal membrane oxygenation for aortic disease is conventionally contraindicated. In this case, a 66‐year‐old man experienced cardiopulmonary arrest caused by acute aortic dissection. When exercising in the gym, he experienced chest discomfort, so the staff immediately called an ambulance. While in the ambulance, he experienced cardiopulmonary arrest. His initial electrocardiogram showed ventricular fibrillation. At the emergency department, we immediately performed extracorporeal cardiopulmonary resuscitation. We suspected acute coronary syndrome, so coronary angiography was carried out. Enlargement of ascending aorta was noted. Whole‐body enhanced computed tomography was subsequently performed, leading to a final diagnosis of acute aortic dissection.OutcomeEmergency ascending aorta prosthesis implantation was performed. The patient received intensive care and was discharged on day 49 of hospitalization. His cerebral performance category score was 4 at discharge.ConclusionThis case suggests that veno‐arterial extracorporeal membrane oxygenation may be used for patients with aortic dissection presenting with cardiac arrest.Electrocardiogram, coronary angiogram and descending aorta angiogram at hospital admission.
      PubDate: 2017-12-19T05:10:39.356555-05:
      DOI: 10.1002/ams2.324
       
  • High‐dose steroid therapy for acute respiratory distress syndrome
           lacking common risk factors: predictors of outcome
    • Authors: Yoshiaki Kinoshita; Hiroshi Ishii, Hisako Kushima, Kentaro Watanabe, Masaki Fujita
      Abstract: AimAcute respiratory distress syndrome (ARDS) is a life‐threatening lung disease that usually occurs in patients with the underling risk factors that triggers lung inflammation. We sometimes encounter patients with ARDS lacking common risk factors. Recent studies have indicated the effectiveness of corticosteroids for this cohort. However, the characteristics of survivors with ARDS who lack common risk factors, and who received high‐dose methylprednisolone pulse therapy (MPPT), are not known.MethodsWe undertook a retrospective study of patients with ARDS lacking common risk factors, who received i.v. MPPT for 3 days. The patients (n = 46) were classified into two groups, survivors (n = 23) and non‐survivors (n = 23), based on their survival at 60 days after the initiation of MPPT, and their clinical and radiological parameters were evaluated.ResultsThe patient characteristics and disease severity of the two groups were comparable. The percentage of consolidation/(ground‐glass attenuation [GGA] + consolidation) on the chest computed tomography scans of survivors was significantly lower than that of non‐survivors (survivors, 5.63% [2.31–13.8] versus non‐survivors, 27.2% [5.97–41.4]; P = 0.01). In the stratified analysis, the percentage of consolidation/(GGA + consolidation) was significantly associated with 60‐day survival.ConclusionsOur results show that the percentage of consolidation/(GGA + consolidation) on the chest CT scans is an independent prognostic factor for patients with ARDS lacking common risk factors after MPPT.Acute respiratory distress syndrome (ARDS) is usually resistant to treatment, but ARDS lacking common risk factors sometimes shows responsiveness to corticosteroid treatment. We found that the low percentage of consolidation/(ground‐glass attenuation + consolidation) on chest computed tomography scans was associated with a significant increase in 60‐day survival in patients with ARDS lacking common risk factors.
      PubDate: 2017-10-25T21:30:27.254747-05:
      DOI: 10.1002/ams2.321
       
  • Contrast medium‐induced transient severe leukopenia
    • Authors: Takashi Hongo; Satoshi Nozaki, Midori Tsuchiya, Mototaka Inaba, Kenji Takahashi, Toshifumi Fujiwara
      Abstract: CaseContrast medium‐induced transient leukopenia is very rare. Here, we report a case of a 73‐year‐old man diagnosed with contrast media‐induced transient leukopenia. The patient underwent abdominal contrast‐enhanced computed tomography, where he was given non‐ionic iodinated contrast medium i.v. His medical history included an allergic reaction to a different contrast medium. One hour later, the patient was admitted to the emergency department complaining of chest discomfort. He had leukopenia and a fever (temperature of 38.9°C). Complete blood count showed a white blood cell count of 930/μL and an absolute neutrophilic count of 232/μL.OutcomeThe patient was given i.v. antibiotics and 5 mg chlorpheniramine maleic acid, 20 mg famotidine, and 125 mg methylprednisolone. The patient's white blood cell count recovered the next day, and he was discharged after 2 days of hospitalization.ConclusionWe diagnosed the patient with contrast media‐induced transient leukopenia, which is a rare phenomenon.Our article reports a rare case of a patient that developed transient agranulocytosis after receiving a contrast medium for abdominal contrast‐enhanced computed tomography. We diagnosed the patient with idiosyncratic agranulocytosis that was induced by the contrast medium, which is a rare phenomenon.
      PubDate: 2017-10-25T21:20:38.538407-05:
      DOI: 10.1002/ams2.319
       
  • Adherence rate of quality‐of‐care indicators for Staphylococcus aureus
           bacteremia is extremely low in Japanese emergency and critical care
           departments: a multicenter retrospective observational study
    • Authors: Kyohei Miyamoto; Seiya Kato, Junichi Kitayama, Junpei Okawa, Ayana Okamoto, Jun Kamei, Kazuhisa Yoshiya, Hideki Asai, Shingo Adachi, Hidekazu Yukioka, Hiroshi Akimoto, Kazuo Okuchi
      Abstract: AimStaphylococcus aureus bacteremia causes significant morbidity and mortality and requires specific management to prevent complications. Most studies evaluating quality of care have been carried out in Europe and North America, and accurate epidemiological data are lacking in Asia. We aimed to describe the epidemiology and evaluate the quality of care for S. aureus bacteremia in Japan.MethodsFrom February 2011 to January 2014, we undertook a multicenter retrospective observational study in 10 departments of emergency and critical care in Japan. We included 118 hospitalized adult patients with S. aureus bacteremia and evaluated three quality‐of‐care indicators: follow‐up blood culture, treatment duration, and echocardiography.ResultsThe mean age of the patients was 63.5 ± 17.0 years. The major source of bacteremia was pneumonia (n = 22, 19%), followed by skin and soft tissue infection (n = 18, 15%). Thirty patients (25%) died in the hospital. Follow‐up blood culture was performed in 21/112 patients (19%). The duration of antimicrobial treatment was sufficient in 49/87 patients (56%). Echocardiography for patients with clinical indication was undertaken in 39/59 patients (66%). Any of the three indicators were inadequate in 101/118 (86%).ConclusionThe rate of adequate care for S. aureus bacteremia is low in Japan. The low adherence rate for follow‐up blood culture was particularly notable. Staphylococcus aureus bacteremia can be an important target of quality improvement interventions.In this multicenter retrospective observational study, we evaluated the quality of care for Staphylococcus aureus bacteremia in Japan. This study revealed that most patients with S. aureus bacteremia (101/108; 86%) were treated inadequately.
      PubDate: 2017-10-25T20:40:50.494659-05:
      DOI: 10.1002/ams2.316
       
  • Promising novel therapy with hydrogen gas for emergency and critical care
           medicine
    • Authors: Motoaki Sano; Masaru Suzuki, Koichiro Homma, Kei Hayashida, Tomoyoshi Tamura, Tadashi Matsuoka, Yoshinori Katsumata, Shuko Onuki, Junichi Sasaki
      Abstract: It has been reported that hydrogen gas exerts a therapeutic effect in a wide range of disease conditions, from acute illness such as ischemia–reperfusion injury, shock, and damage healing to chronic illness such as metabolic syndrome, rheumatoid arthritis, and neurodegenerative diseases. Antioxidant and anti‐inflammatory properties of hydrogen gas have been proposed, but the molecular target of hydrogen gas has not been identified. We established the Center for Molecular Hydrogen Medicine to promote non‐clinical and clinical research on the medical use of hydrogen gas through industry–university collaboration and to obtain regulatory approval of hydrogen gas and hydrogen medical devices (http://www.karc.keio.ac.jp/center/center-55.html). Studies undertaken by the Center have suggested possible therapeutic effects of hydrogen gas in relation to various aspects of emergency and critical care medicine, including acute myocardial infarction, cardiopulmonary arrest syndrome, contrast‐induced acute kidney injury, and hemorrhagic shock.It has been reported that hydrogen gas exerts its therapeutic effect in a wide range of disease condition from acute illness such as ischemia reperfusion injury, shock, damage healing to chronic illness such as metabolic syndrome, rheumatoid arthritis and neurodegenerative diseases. Antioxidant and anti‐inflammatory properties of hydrogen gas have been proposed, but the molecular target of hydrogen gas has not been identified. We established the Center for Molecular Hydrogen Medicine to promote nonclinical and clinical research on medical use of hydrogen gas through industry‐university collaboration and to obtain regulatory approval of hydrogen gas and hydrogen medical devices (http://www.karc.keio.ac.jp/center/center-55.html). Studies performed by the Center have suggested possible therapeutic effects of hydrogen gas in relation to various aspects of emergency and critical care medicine, including acute myocardial infarction, cardiopulmonary arrest syndrome, contrast‐induced acute kidney injury, and hemorrhagic shock.
      PubDate: 2017-10-24T07:15:22.71535-05:0
      DOI: 10.1002/ams2.320
       
  • Coin pica‐induced gastric perforation resulting from ingestion of 1,894
           coins, 8 kg in total: case report and review of published works
    • Authors: Kosuke Sekiya; Shusuke Mori, Yasuhiro Otomo
      Abstract: CasePica is common among patients with psychiatric disorders, but only a few cases regarding coin pica have been reported. A 51‐year‐old man with depression complaining of fatigue was found to have numerous coins in the esophagus and the stomach on X‐rays. He had a peritoneal sign and underwent an emergency laparotomy.OutcomeThe surgical findings showed perforation on the anterior wall of the gastric body and coins in the stomach, which were removed manually, followed by an omental patch. Residual coins in the esophagus were removed by endoscopy. The coins totaled 1,894, weighing 8,076 grams. The patient was then diagnosed as schizophrenic. He was asymptomatic for metal toxicity and was finally transferred to a psychiatric hospital.ConclusionThis pica case is the first to show coin pica can lead to gastric perforation, and also reports the largest amounts of coins ingested by a person to date.A 51‐year‐old man with schizophrenia, who was found to have numerous coins in the esophagus and stomach, underwent an emergency operation for peritonitis. A few cases regarding coin pica have been reported. This case was the first showing gastric perforation and the largest number of ingested coins.
      PubDate: 2017-10-24T07:10:26.0347-05:00
      DOI: 10.1002/ams2.318
       
  • Two cases of spontaneous cervical epidural hematoma without back or neck
           pain in elderly Japanese men
    • Authors: Takashi Hongo; Kenichi Iseda, Midori Tsuchiya, Mototaka Inaba, Satoshi Nozaki, Kenji Takahashi, Masaaki Nakajima, Toshifumi Fujiwara
      Abstract: CasesSpontaneous spinal epidural hematoma (SSEH) is an uncommon disease. Most SSEH cases involve back and/or neck pain. We report the cases of two men who experienced SSEH with dysstasia but without back or neck pain.OutcomesThis study presents two cases involving elderly Japanese men who visited an emergency department because of sudden dysstasia without back or neck pain. The results of the neurological examinations revealed ataxic gait. Cervical spinal epidural hematomas were observed by computed tomography and magnetic resonance imaging. One patient underwent hematoma removal and decompression by corpectomy, whereas the other patient received conservative treatment and observation. The patients were discharged without sequelae.ConclusionSpinal epidural hematomas are difficult to diagnose, and a delayed diagnosis can adversely affect the patient's quality of life. These hematomas should be considered in the differential diagnosis of cerebrovascular diseases.This figure shows spinal epidural hematoma. We performed hematoma removal and decompression by corpectomy from the front of C3‐5.
      PubDate: 2017-10-24T07:00:53.29768-05:0
      DOI: 10.1002/ams2.317
       
  • Lemierre's syndrome presented with acute pancreatitis
    • Authors: Laura Garcia; Kaori Ito
      Abstract: CaseLemierre's syndrome is a rare clinical condition that is characterized by infected internal jugular vein thrombosis with metastatic septicemia. The most common causative agent is Fusobacterium necrophorum. A previously healthy 37‐year‐old woman presented to our emergency department with nausea, vomiting, and diarrhea. She was admitted to the general practice unit with a diagnosis of acute pancreatitis then was subsequently transferred to the intensive care unit due to shock. Physical examination revealed tenderness on right side of the neck. Blood cultures were remarkable for F. necrophorum. Clinical symptoms led to subsequent ultrasound and computed tomography scan of the neck, confirming internal jugular vein thrombosis.OutcomeThe patient was treated with antibiotics for 6 weeks. Anticoagulation therapy was initiated.ConclusionWe report a case of Lemierre's syndrome that presented as acute pancreatitis. The high index of suspicion of this disease is important for early diagnosis.Lemierre's syndrome is a rare clinical condition characterized by infected internal jugular vein thrombosis with metastatic septicemia caused by Fusobacterium necrophorum. We experienced a patient with Lemierre's syndrome that presented as acute pancreatitis.
      PubDate: 2017-10-20T00:35:32.983085-05:
      DOI: 10.1002/ams2.314
       
  • Quality of dispatch‐assisted cardiopulmonary resuscitation by lay
           rescuers following a standard protocol in Japan: an observational
           simulation study
    • Authors: Hideki Asai; Hidetada Fukushima, Francesco Bolstad, Kazuo Okuchi
      Abstract: AimBystander cardiopulmonary resuscitation (CPR) is essential for improving the outcomes of sudden cardiac arrest patients. It has been reported that dispatch‐assisted CPR (DACPR) accounts for more than half of the incidence of CPR undertaken by bystanders. Its quality, however, can be suboptimal. We aimed to measure the quality of DACPR using a simulation study.MethodsWe recruited laypersons at a shopping mall and measured the quality of CPR carried out in our simulation. Dispatchers provided instruction in accordance with the standard DACPR protocol in Japan.ResultsTwenty‐three laypersons (13 with CPR training experience within the past 2 years and 10 with no training experience) participated in this study. The median chest compression rate and depth were 106/min and 33 mm, respectively. The median time interval from placing the 119 call to the start of chest compressions was 119 s. No significant difference was found between the groups with and without training experience. However, subjects with training experience more frequently placed their hands correctly on the manikin (84.6% versus 40.0%; P = 0.026). Twelve participants (52.2%, seven in trained and five in untrained group) interrupted chest compressions for 3–18 s, because dispatchers asked if the patient started breathing or moving.ConclusionThis current simulation study showed that the quality of DACPR carried out by lay rescuers can be less than optimal in terms of depth, hand placement, and minimization of pauses. Further studies are required to explore better DACPR instruction methods to help lay rescuers perform CPR with optimal quality.The quality of dispatch‐assisted cardiopulmonary resuscitation (DACPR) performed by lay rescuers can be suboptimal. We conducted a DACPR simulation study as if a lay rescuer happens to encounter a cardiac arrest situation and observed how they perform CPR under dispatch instruction.
      PubDate: 2017-10-11T07:30:21.641155-05:
      DOI: 10.1002/ams2.315
       
  • Development of the Japanese version of the Cornell Assessment of Pediatric
           Delirium
    • Authors: Haruhiko Hoshino; Yujiro Matsuishi, Nobutake Shimojo, Yuki Enomoto, Takahiro Kido, Yoshiaki Inoue
      Abstract: AimDelirium is a form of acute cerebral dysfunction and is associated with increased length of hospital stay, mortality, and health‐care costs for adult patients in intensive care. However, in Japan, there are currently no reliable criteria or tools for diagnosing delirium in critically ill pediatric patients. The purpose of this study was to translate the Cornell Assessment of Pediatric Delirium (CAPD)—a screening tool for pediatric delirium—from English to Japanese for use in the diagnosis of delirium for pediatric patients in pediatric intensive care units.MethodsThe back‐translation method was used to ensure equivalence in the Japanese version of the CAPD and its accompanying developmental anchor points. The translation process was repeated by a multidisciplinary committee of medical researchers and clinicians.ResultsThe final back‐translated version of the CAPD was submitted to the original author, who gave her approval.ConclusionThe Japanese CAPD was developed and its effectiveness tested using a standardized procedure. Further study is required to test the validity and reliability of the Japanese version of the CAPD.This study investigated Japanese version of CAPD which is delirium screening tool in pediatric intensive care unit. We developed Japanese version of CAPD to use back translation method.
      PubDate: 2017-10-03T05:45:09.403776-05:
      DOI: 10.1002/ams2.312
       
  • Accuracy of the smaller superior mesenteric vein sign for the detection of
           acute superior mesenteric artery occlusion
    • Authors: Takaaki Nakano; Toshitaka Ito, Tetsuhiro Takei, Masaaki Takemoto
      Abstract: AimsThe smaller superior mesenteric vein (SMV) sign is a well‐known computed tomography (CT) parameter for acute superior mesenteric artery (SMA) occlusion. This CT sign is potentially beneficial for the early diagnosis of acute SMA occlusion; however, few reports have documented this sign. The present study aimed to determine the accuracy of the smaller SMV sign for the detection of acute SMA occlusion.MethodsWe retrospectively reviewed CT images from 20 patients with acute SMA occlusion and 1,216 controls. We measured the external diameters of the SMV and SMA, and calculated the SMV/SMA diameter ratio. A ratio ≤1 indicated a positive smaller SMV sign.ResultsOf the 20 patients, 14 had the smaller SMV sign, whereas of the 1,216 controls, 88 had the smaller SMV sign. Of the 88 controls with a positive sign, 79 had apparent reasons for the decreased flow in the SMA and nine patients had no reason for the decreased flow. The sensitivity and specificity of the smaller SMV sign for acute SMA occlusion were 70% and 99.2%, respectively.ConclusionThe smaller SMV sign is an accurate and important CT parameter for the detection of acute SMA occlusion.Smaller superior mesenteric vein sign on acute superior mesenteric artery occlusion.
      PubDate: 2017-09-28T02:47:30.727449-05:
      DOI: 10.1002/ams2.313
       
  • Development of the Japanese version of the Preschool Confusion Assessment
           Method for the ICU
    • Authors: Yujiro Matsuishi; Haruhiko Hoshino, Nobutake Shimojo, Yuki Enomoto, Takahiro Kido, Subrina Jesmin, Masahiko Sumitani, Yoshiaki Inoue
      Abstract: AimDelirium is associated with various negative clinical outcomes, such as decline in cognitive ability, increased length of hospital stay, and higher mortality. For these reasons, early diagnosis of delirium is critical. Unfortunately, there are no reliable diagnostic criteria or tool of delirium for infants and preschool‐aged children in Japan.The aim of the present study was to translate a new delirium assessment tool, the Preschool Confusion Assessment Method for the Intensive Care Unit (psCAM‐ICU), for accurately diagnosing clinically ill infants and preschool‐aged children, from English to Japanese.MethodsThe translation was undertaken with the internationally established back‐translation method. The translation was repeated blindly and independently by eight medical researchers and clinicians from multiple disciplines. Any discrepancy evident from the translated works was discussed and resolved.ResultsWe report the successful development of the Japanese version of psCAM‐ICU. However, before its full application, this diagnostic tool requires further testing and study, most notably for its validation and reliability.ConclusionA Japanese version of the psCAM‐ICU was developed.A Japanese Version of The Preschool Confusion Assessment Method for the ICU(psCAM‐ICU) was developed
      PubDate: 2017-09-15T23:16:17.59319-05:0
      DOI: 10.1002/ams2.306
       
  • A case of paraplegia that developed 6 years after thoracic endovascular
           aortic repair for blunt traumatic aortic injury
    • Authors: Hiroyuki Takahashi; Tomohisa Shoko, Fumino Taketazu, Keiichi Kuriyama, Kazuhide Yoshikawa, Yoshizumi Deguchi
      Abstract: CaseThoracic endovascular aortic repair (TEVAR) is becoming the standard therapy for blunt thoracic aortic injury (BTAI). However, the long‐term outcomes of TEVAR for BTAI remain unclear. A 36‐year‐old man was admitted to our emergency department with dyspnea. He had been involved in a serious traffic accident 6 years earlier, requiring TEVAR for BTAI.OutcomeAcute heart failure and pneumonia were diagnosed on this admission. His respiratory condition improved, but paraplegia developed 10 h after hospitalization. Magnetic resonance imaging showed an intraspinal longitudinal area of signal hyperintensity, and spinal cord infarction was diagnosed.ConclusionAlthough the causal relationship between the TEVAR and spinal cord infarction remains unclear, paraplegia as a long‐term complication after TEVAR does not appear to have been reported previously, and so represents a potentially important complication.Thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injury (BTAI) offers lower rates of mortality and complications than open surgical repair, and is becoming the standard therapy. We encountered a case of paraplegia occurring 6 years after TEVAR for BTAI. Although TEVAR for BTAI is an effective treatment that is gaining popularity, long‐term follow‐up appears warranted.
      PubDate: 2017-09-14T02:36:14.55164-05:0
      DOI: 10.1002/ams2.307
       
  • Ulinastatin did not reduce mortality in elderly multiple organ failure
           patients: a retrospective observational study in a single center ICU
    • Authors: Masatoshi Uchida; Toshikazu Abe, Kazuyuki Ono, Nanako Tamiya
      Abstract: AimOur aim was to evaluate the effect of ulinastatin on 28-day mortality in patients who developed multiple organ failure (MOF) related to their acute illness and were admitted to the intensive care unit (ICU).MethodsWe carried out a retrospective observational study of MOF patients in a general ICU of a tertiary care hospital in Japan from January 2009 to December 2012. The primary outcome was 28-day all-cause mortality. Secondary outcomes were ventilator-free days, ICU-free days, and vasopressor-free days at day 28. We investigated the association between ulinastatin treatment and outcomes using multivariable regression analysis.ResultsA total of 212 MOF patients were included, 79 (37%) of whom received ulinastatin. The median age was 70 years (interquartile range, 60–77) and median APACHE II score was 25 (interquartile range, 19–29). Overall 28-day mortality was 20%. There were no significant differences between the ulinastatin group and the control group in age, gender, or APACHE II score. The ulinastatin group had higher prevalence of sepsis (44% versus 22%, P = 0.001). Multivariable logistic regression analysis showed that ulinastatin was not associated with 28-day mortality (odds ratio = 1.22; 95% confidence interval, 0.54–2.79). Moreover, ulinastatin did not reduce the mortality in patients with sepsis (odds ratio = 1.92; 95% confidence interval, 0.52–7.13). However, ICU-free days and ventilator-free days was significantly fewer in the ulinastatin group than control group.ConclusionsIn this retrospective observational study, ulinastatin was not associated with mortality in elderly patients with established MOF, although it might be related to patient's utility.We carried out a retrospective study to investigate the association between ulinastatin treatment and outcomes. This study suggested that ulinastatin treatment should not be associated with favorable outcomes in elderly patients with established MOF.
      PubDate: 2017-08-18T01:57:46.362224-05:
      DOI: 10.1002/ams2.304
       
  • Issue Information
    • First page: 377
      PubDate: 2017-10-02T19:12:31.263916-05:
      DOI: 10.1002/ams2.245
       
  • A review of the history of the origin of triage from a disaster medicine
           perspective
    • Authors: Hiroyuki Nakao; Isao Ukai, Joji Kotani
      First page: 379
      Abstract: We usually associate triage with the Simple Triage and Rapid Treatment method, but much of its origin is still unknown. Therefore, French studies and the origin of triage shown in domestic and foreign published works have been investigated and its significance reaffirmed. The etymology of the word “triage” means “to break into three pieces.” It was suggested by a literature review that the rise of Napoleon led to military tactical changes, and that the prototype of triage arose from the experience gained in the difficult campaign in Egypt and Syria. Subsequently, triage was refined by Napoleon's military surgeon, D. J. Larrey, who created the ambulance transport system. Although there is a clash between the ruthless and philanthropic aspects of triage, triage is in accordance with the primary purpose of evacuation or treatment. We should choose the triage method that is consistent with the purpose of each disaster situation.French studies and the origin of triage shown in domestic and foreign published works have been investigated and its significance reaffirmed. It was suggested by a literature review that the rise of Napoleon led to military tactical changes, and that the prototype of triage arose from the experience gained in the difficult campaign in Egypt and Syria. We should choose the triage method that is consistent with the purpose of each disaster situation.
      PubDate: 2017-07-14T02:20:35.139932-05:
      DOI: 10.1002/ams2.293
       
  • Better documentation in electronic medical records would lead to an
           increased use of lower extremity venous ultrasound in the inpatient
           setting: a retrospective study
    • Authors: Daisuke Takechi; Naoto Kuroda, Hisashi Dote, Euido Kim, Osamu Yonekawa, Takuya Watanabe, Tetsumei Urano, Yoichiro Homma
      First page: 385
      Abstract: AimWe hypothesized that the quality of the assessment of abnormal laboratory data in the emergency department (ED) could affect the hospital-attending physicians’ decision-making after a patient's hospitalization. To test this hypothesis, we investigated how patients with a positive D-dimer result were reported by ED physicians in electronic medical records, and measured whether lower extremity venous ultrasonography examination was undertaken during hospitalization by the hospital-attending physicians.MethodsIn an urban tertiary acute care general hospital in Japan, between January 2012 and December 2013, we included patients hospitalized after a positive D-dimer measurement (≥1.0 μg/mL) that was taken in the emergency department. We retrospectively measured the quality of ED physician assessments. Then we examined whether that affected the decisions of attending physicians to order lower extremity venous ultrasonography examinations during hospitalization. The exposure variable was the quality of the ED physicians’ assessment of patients with positive D-dimer results. The outcome was whether a lower extremity venous ultrasonography examination was ordered by the attending physician during hospitalization.ResultsWhen assessments were described by ED physicians for patients with positive D-dimer results, the attending physicians frequently ordered lower extremity venous ultrasonography (odds ratio, 10.74; 95% confidence interval, 5.92–19.50), even if the assessments only contained “copied and pasted” laboratory data (odds ratio, 1.68; 95% confidence interval, 2.10–2.40).ConclusionsBetter documentation by ED physicians, regarding patients with positive D-dimer results, strongly affected the decisions made by attending physicians to order lower extremity venous ultrasonography examination.Several cross-sectional studies have reported on the quality of electronic medical records (EMRs) in the clinical setting, whereas a study has shown the ease with which copy and paste can be used in EMRs. However, none of these studies could answer how much copied-and-pasted documentation was transmitted between physicians by the EMRs, and none investigated the influence of the assessment quality by the EMRs in a cohort setting, even retrospectively. Better documentation by emergency department physicians, regarding patients with positive D-dimer results, strongly affected the decisions made by attending physicians to order lower extremity venous ultrasonography examination.
      PubDate: 2017-06-19T21:35:30.871412-05:
      DOI: 10.1002/ams2.289
       
  • Venous thromboembolism in major trauma patients: a single-center
           retrospective cohort study of the epidemiology and utility of D-dimer for
           screening
    • Authors: Tetsuya Yumoto; Hiromichi Naito, Yasuaki Yamakawa, Atsuyoshi Iida, Kohei Tsukahara, Atsunori Nakao
      First page: 394
      Abstract: AimVenous thromboembolism (VTE) can be a life-threatening complication after major trauma. The aim of this study was to investigate the epidemiology of VTE and to assess the usefulness of D-dimer for screening for VTE in major trauma cases among the Japanese population.MethodsWe examined a single-center retrospective cohort of severely injured trauma patients who had been admitted to the emergency intensive care unit at Okayama University Hospital (Okayama, Japan) from April 2013 through to March 2016. Venous thromboembolism was confirmed by computed tomography angiography and computed tomography venography, which was determined based on the attending physician monitoring daily D-dimer levels. Independent risk factors for VTE were determined by multiple logistic regression analysis. D-dimer levels were evaluated using area under the receiver operating characteristic curve (AUROC) to predict VTE.ResultsThe study cohort consisted of 204 trauma patients (median Injury Severity Score, 20). Of the 204 patients, 65 (32%) developed VTE. The median time from admission to VTE diagnosis was 10 days. In multiple logistic regression analysis, higher Injury Severity Score and the presence of lower extremity fractures were revealed to be a risk factor for VTE. D-dimer levels at day 10 showed moderate accuracy, of which the AUROC was 0.785 (95% confidence interval, 0.704–0.866; P < 0.001). The cut-off that maximized the Youden index was 12.45 μg/mL.ConclusionsAt least one of every three major trauma patients had potential development of VTE at a median of 10 days following admission to the intensive care unit. D-dimer levels on day 10 can be a useful predictor of VTE.This is the first investigation regarding venous thromboembolism (VTE) in major trauma among Japanese patients. At least one of every three major trauma patients developed VTE at a median of 10 days following admission to the intensive care unit. D-dimer levels on day 10 can be a useful predictor of VTE.
      PubDate: 2017-06-19T21:15:54.292276-05:
      DOI: 10.1002/ams2.290
       
  • Evaluation of factors associated with the difficulty in finding receiving
           hospitals for traffic accident patients at the scene treated by emergency
           medical services: a population-based study in Osaka City, Japan
    • Authors: Yusuke Katayama; Tetsuhisa Kitamura, Kosuke Kiyohara, Taku Iwami, Takashi Kawamura, Sumito Hayashida, Hiroshi Ogura, Takeshi Shimazu
      First page: 401
      Abstract: AimAlthough the prolongation of the time between injury and hospital arrival of traffic accident patients can influence their prognosis, factors associated with the difficulty in hospital acceptance of these patients have not been sufficiently evaluated in Japan.MethodsWe retrospectively analyzed the population-based ambulance records of all traffic accident patients for whom the Osaka Municipal Fire Department (Osaka City, Japan) dispatched an ambulance in 2013. We defined “cases with difficulty in hospital acceptance” as cases that required ≥4 calls by emergency medical service personnel at the scene before receiving hospital acceptance. We included patient characteristics (age, sex, coma status, and trauma severity judged by emergency medical service personnel), time factors (day/night or weekday/holiday and weekends), and accident location for multivariable logistic regression analysis to assess factors associated with the difficulty in hospital acceptance.ResultsAmong 13,427 traffic accident patients, 2,033 (15.1%) were cases with difficulty in hospital acceptance. Pediatric patients (adjusted odds ratio [OR], 1.265; 95% confidence interval [CI], 1.060–1.509), male sex (adjusted OR, 1.260; 95% CI, 1.135–1.398), moderate-grade trauma (adjusted OR, 2.241; 95% CI, 1.972–2.547), severe-grade trauma (adjusted OR, 2.057; 95% CI, 1.249–3.388), holidays and weekends (adjusted OR, 1.702; 95% CI, 1.539–1.882), and night-time (adjusted OR, 2.720; 95% CI, 2.443–3.027) were positively associated with difficulty in hospital acceptance.ConclusionsUsing population-based ambulance records from a large urban community in Japan, we showed that the difficulty in hospital acceptance of patients at the scene of traffic accidents was positively associated with several prehospital factors.We assessed the relationship between the difficulties in hospital acceptance of patients at the scene of traffic accidents by using population-based ambulance records from a large urban community in Japan. We showed that the difficulty in hospital acceptance of patients at the scene of traffic accidents was positively associated with several prehospital factors, such as night-time and severity of trauma.
      PubDate: 2017-06-16T01:50:24.231236-05:
      DOI: 10.1002/ams2.291
       
  • Respiratory extracorporeal membrane oxygenation for severe sepsis and
           septic shock in adults: a propensity score analysis in a multicenter
           retrospective observational study
    • Authors: Shuhei Takauji; Mineji Hayakawa, Kota Ono, Hiroshi Makise
      First page: 408
      Abstract: AimThis multicenter retrospective observational study aimed to evaluate the efficacy of extracorporeal membrane oxygenation (ECMO) support for septic patients with severe respiratory failure using propensity score analyses.MethodsThe data of severe sepsis patients from 42 intensive care units between January 2011 and December 2013 were retrospectively collected. Propensity score matching analyses were undertaken for severe respiratory failure patients with/without veno-venous ECMO support. The main outcome was in-hospital all-cause mortality.ResultsOf 3195 patients with severe sepsis, 570 had severe respiratory failure. Forty patients in the ECMO group were matched with 150 patients in the control group. A survival time analysis revealed no difference in the in-hospital survival (hazard ratio, 0.854; 95% confidence interval, 0.531–1.373; P = 0.515). Two-hundred and eighty-five patients had severe respiratory failure induced by lung infection. Twenty-five ECMO group patients were matched with 89 patients in the control group. In the ECMO group, the survival time was longer than in the control group (hazard ratio, 0.498; 95% confidence interval, 0.279–0.889; P = 0.018). The number of renal replacement therapy- and vasopressor-free days improved. The ECMO group received more red blood cells transfused than the control group, but there was no significant difference in the rate of severe bleeding complications between the groups.ConclusionsThere was no difference in the in-hospital survival between the ECMO group and control group among overall septic patients with severe respiratory failure. However, in sepsis patients with severe respiratory failure induced by lung infection, ECMO support may improve their survival time.Among septic patients with severe respiratory failure induced by lung infection, the survival time in the extracorporeal membrane oxygenation (ECMO) group was significantly longer than in the control group. Therefore, in sepsis patients with severe respiratory failure induced by lung infection, ECMO support may improve their survival time.
      PubDate: 2017-07-17T20:45:32.143825-05:
      DOI: 10.1002/ams2.296
       
  • Influence of body position during Heimlich maneuver to relieve
           supralaryngeal obstruction: a manikin study
    • Authors: Michitaro Ichikawa; So Oishi, Katsunori Mochizuki, Kenichi Nitta, Kazufumi Okamoto, Hiroshi Imamura
      First page: 418
      Abstract: AimTo study the most effective body position for Heimlich maneuver.MethodsA choking simulation manikin was connected to a laryngeal model of a child or an adult, and a differential pressure transducer recorded the airway pressure and waveform during the maneuver. A konjac jelly was placed on the larynx to mimic complete supralaryngeal obstruction. The maneuver (five successive compressions) was carried out six times each in standing, prone, and supine positions. For cases of children, we added a supine position with a pillow under the back.ResultsIn the adult model, airway obstruction was more frequently relieved in the supine and prone positions than in the standing position (P < 0.001). In the child model, airway obstruction was more frequently relieved in the supine position, with a pillow, and in the prone position, than in the standing position (P < 0.001). Without relief, successive Heimlich maneuvers made the airway pressure increasingly negative (adult, from −21.9 ± 6.5 cmH2O to −31.5 ± 9.1 cmH2O in the standing position [P < 0.001]; child, from −15.0 ± 9.5 cmH2O to −30.0 ± 9.2 cmH2O in the standing position [P < 0.001] and from −35.0 ± 17.4 cmH2O to −47.3 ± 25.1 cmH2O in the supine position without a pillow [P = 0.002]).ConclusionsThe Heimlich maneuver was more effective in the supine and prone positions. In children, the prone position may be most effective. Successive Heimlich maneuvers may be harmful when the airway is not relieved after the first compression.When there was no foreign body in the airway, there was little change in the airway pressure (top panel). In the case of an obstructed airway, the airway pressure showed a transient positive wave followed by a large negative wave (middle panel). Thus, airway pressure can be used to determine whether the airway is obstructed.
      PubDate: 2017-07-17T20:50:46.288202-05:
      DOI: 10.1002/ams2.297
       
  • Early evaluation of severity in patients with severe sepsis: a comparison
           with “septic shock” — subgroup analysis of the Japanese Association
           for Acute Medicine Sepsis Registry (JAAM-SR)
    • Authors: Takehiko Tarui; Yoshihiro Yamaguchi, Koichiro Suzuki, Ryosuke Tsuruta, Hiroto Ikeda, Hiroshi Ogura, Shigeki Kushimoto, Joji Kotani, Shin-ichiro Shiraishi, Yasushi Suzuki, Kiyotsugu Takuma, Naoshi Takeyama, Seitaro Fujishima, Toshihiko Mayumi, Yasuo Miki, Norio Yamashita, Naoki Aikawa, Satoshi Gando
      First page: 426
      Abstract: AimThe purpose of this subgroup analysis of a Japanese multicenter registry, the Japanese Association for Acute Medicine Sepsis Registry Advanced (JAAM-SR-Advanced), was to identify early outcome indicators for severe sepsis that are useful and more objective than “septic shock.”MethodsAmong 624 patients with severe sepsis registered in JAAM-SR-Advanced, 554 with valid serum lactate data were retrospectively studied. Hypotension before and after fluid resuscitation and the highest lactate values over the initial 24 h were compared for their ability to predict in-hospital mortality.ResultsOf the study group, 155 (28.0%) patients were non-survivors and had significantly lower systolic blood pressures and higher lactate peaks. The mortality of 364 patients with initial hypotension was higher than those patients without it (32.7% versus 19.1%, P 
      PubDate: 2017-07-27T00:05:27.582319-05:
      DOI: 10.1002/ams2.299
       
  • Comparison of registry and government evaluation data to ascertain severe
           trauma cases in Japan
    • Authors: Shinji Nakahara; Tetsuya Sakamoto, Takashi Fujita, Tomohide Koyama, Yoichi Katayama, Seizan Tanabe, Yasuhiro Yamamoto
      First page: 432
      Abstract: AimsAccurate evaluation of health care quality requires high-quality data, and case ascertainment (confirming eligible cases and deaths) is a foundation for accurate data collection. This study examined the accuracy of case ascertainment from two Japanese data sources.MethodsUsing hospital-level data, we investigated the concordance in ascertaining trauma cases between a nationwide trauma registry (the Japan Trauma Data Bank) and annual government evaluations of tertiary hospitals between April 2012 and March 2013. We compared the median values for trauma case volumes, numbers of deaths, and case fatality rates from both data sources, and also evaluated the variability in discrepancies for the intrahospital differences of these outcomes.ResultsThe analyses included 136 hospitals. In the registry and annual evaluation data, the median case volumes were 120.5 cases and 180.5 cases, respectively; the median numbers of deaths were 11 and 12, respectively; and the median case fatality rates were 8.1% and 6.4%, respectively. There was broad variability in the intrahospital differences in these outcomes.ConclusionsThe observed discordance between the two data sources implies that these data sources may have inaccuracies in case ascertainment. Measures are needed to evaluate and improve the accuracy of data from these sources.We compared case ascertainment in the Japan Trauma Data Bank and the annual government evaluation of tertiary hospitals. There was considerable discordance between the two data sources. Measures are needed to improve data quality in these data sources
      PubDate: 2017-08-07T21:35:56.669923-05:
      DOI: 10.1002/ams2.302
       
  • Effectiveness of dispatcher training in increasing bystander chest
           compression for out-of-hospital cardiac arrest patients in Japan
    • Authors: Taichiro Tsunoyama; Shinji Nakahara, Masafumi Yoshida, Maki Kitamura, Tetsuya Sakamoto
      First page: 439
      Abstract: AimThe Japanese government has developed a standardized training program for emergency call dispatchers to improve their skills in providing oral guidance on chest compression to bystanders who have witnessed out-of-hospital cardiac arrests (OHCAs). This study evaluated the effects of such a training program for emergency call dispatchers in Japan.MethodsThe analysis included all consecutive non-traumatic OHCA patients transported to hospital by eight emergency medical services, where the program was implemented as a pilot project. We compared the provision of oral guidance and the incidence of chest compression applications by bystanders in the 1-month period before and after the program. Data collection was undertaken from October 2014 to March 2015.ResultsThe 532 non-traumatic OHCA cases were used for analysis: these included 249 cases before and 283 after the guidance intervention. Most patients were over 75 years old and were men. After the program, provision of oral guidance to callers slightly increased from 63% of cases to 69% (P = 0.13) and implementation of chest compression on patients by bystanders significantly increased from 40% to 52% (P = 0.01). Appropriate chest compression also increased from 34% to 47% (P = 0.01). In analysis stratified by the provision of oral guidance, increased chest compressions were observed only under oral guidance.ConclusionsWe found increased provision of oral guidance by dispatchers and increased appropriate chest compressions by bystanders after the training program for dispatchers had been rolled out. Long-term observation and further data analysis, including patient outcomes, are needed.After the standardized training program for dispatchers, cases of implementation of chest compressions by bystanders and appropriate chest compressions significantly increased. Cases of chest compressions and appropriate chest compressions increased only under oral guidance.
      PubDate: 2017-08-07T21:40:29.582661-05:
      DOI: 10.1002/ams2.303
       
  • Two cases with intra-aortic balloon pumping use for severe septic
           cardiomyopathy
    • Authors: Taro Hiromi; Chiaki Toida, Takashi Muguruma, Katsutaka Hashiba, Tomoki Doi, Kyota Nakamura, Naoto Morimura
      First page: 446
      Abstract: CasesSeptic cardiomyopathy is defined as a reversible left ventricular systolic dysfunction. Patients with severe septic cardiomyopathy have a high mortality rate, even if they receive conventional therapy. For those patients, previous reports showed intra-aortic balloon pump (IABP) efficacy. We report two rare cases with IABP introduction leading them to drastic improvement, and survival from severe septic cardiomyopathy. Case 1 is a 78-year-old woman diagnosed with renal calculus pyelonephritis, septic shock, and septic cardiomyopathy. Case 2 is a 62-year-old man diagnosed with pneumonia, septic shock, and septic cardiomyopathy.OutcomeIn both cases, despite conventional therapy for cardiomyopathy, including high-dose catecholamine therapy, shock was not reversed, and the IABP was inserted. Circulatory status was improved after the introduction of the IABP.ConclusionOur findings suggest that an IABP can be useful for salvaging patients with septic cardiomyopathy who do not respond to conventional therapy.The intra-aortic balloon pump was a highly effective mechanic device in our two patients with severe septic cardiomyopathy. The clinical course of these two cases indicated that the intra-aortic balloon pump could be useful for managing septic cardiomyopathy that does not response sufficiently to conventional therapy.
      PubDate: 2017-07-13T23:05:29.420354-05:
      DOI: 10.1002/ams2.292
       
  • Endoscopic hematoma evacuation for acute subdural hematoma in a young
           patient: a case report
    • Authors: Atsushi Kuge; Daisuke Tsuchiya, Shigeki Watanabe, Mitsuya Sato, Toshihiko Kinjo
      First page: 451
      Abstract: CaseThe standard treatment for acute subdural hematoma (ASDH) is large craniotomy; decompressive craniectomy may also be carried out, if needed, to prevent secondary brain damage. Recently, an endoscopic procedure for elderly patients with ASDH was carried out and reported; its safety and effectiveness were emphasized because of minimal invasiveness. We report a young case and discuss its difficulties and tips.A 31-year-old man was found to be in a state of general convulsion. At the time of admission, we observed severe consciousness disturbance, anisocoria, and left hemiparesis. Computed tomography showed a massive subdural hematoma with marked midline shift.OutcomeOsmotherapy and emergency trepanation improved anisocoria. An endoscopic procedure under local anesthesia was sequentially selected. After surgery, the patient's symptoms clearly improved.ConclusionAlthough the standard treatment for ASDH is craniotomy, endoscopic surgery may be useful in some cases.Although endoscopic procedure for young patients with acute subdural hematoma has not been previously reported, we report an experience of endoscopic hematoma evacuation for acute subdural hematoma in a 31 year-old male patient and describe advantages and some tips for the endoscopic procedure.
      PubDate: 2017-07-17T20:40:41.658017-05:
      DOI: 10.1002/ams2.295
       
  • A case of disseminated cryptococcosis with necrotizing fasciitis in a
           non-HIV patient
    • Authors: Tetsuya Hoshino; Kazuya Omura, Shinichi Kimura, Hiroyuki Takahashi, Katsuhiko Kamei, Misako Ohkusu
      First page: 454
      Abstract: CaseDisseminated cryptococcosis is a well-recognized condition among HIV patients, but it also occurs in non-HIV patients. Necrotizing fasciitis caused by cryptococcus is rare. An 81-year-old man who had received steroid therapy presented with erythema and pain in his right thigh. After the rapid progression of symptoms and a failure to respond to antibiotic therapy, a clinical diagnosis of necrotizing fasciitis was made. We performed debridement, and yeasts were detected using a Gram stain of the fascia. We treated the patient with liposomal amphotericin B. On day 3, he developed meningitis. Cryptococcus neoformans was detected in the blood, fascia, and cerebrospinal fluid. Flucytosine was added to liposomal amphotericin B.OutcomeDespite the antifungal treatment, new regions of dissemination to the skin developed, and the patient died of multiple organ failure.ConclusionA diagnosis of disseminated cryptococcosis should be considered in a differential diagnosis of necrotizing fasciitis among immunocompromised patients, regardless of their HIV status.Necrotizing fasciitis is very rare form of cryptococcosis and the prognosis is poor. Early diagnosis and early debridement with antifungal therapy are necessary to improve the outcome.
      PubDate: 2017-07-13T05:20:25.643934-05:
      DOI: 10.1002/ams2.298
       
  • Basi-parallel anatomical scanning–magnetic resonance imaging for the
           diagnosis of reversible cerebral vasoconstriction syndrome of the basilar
           artery: a case report
    • Authors: Akitaka Yamamoto; Yukinari Omori, Akihiro Shindo, Hiroshi Imai, Hidenori Suzuki
      First page: 458
      Abstract: CaseReversible cerebral vasoconstriction syndrome (RCVS) is an increasingly recognized and important cause of thunderclap headache. Delays in diagnosis may cause deterioration of symptoms and concomitant unnecessary investigations. However, the diagnosis of RCVS in the acute stage remains difficult.A 41-year-old man was admitted to the emergency department for severe, recurrent occipital headaches. The results of initial computed tomography and magnetic resonance imaging (MRI) of the brain and cerebrospinal fluid analysis were normal. Magnetic resonance angiography (MRA) showed multisegmental luminal stenosis of the basilar artery. Basi-parallel anatomical scanning (BPAS)-MRI, illustrating the outer contour of the vertebrobasilar artery, also showed multisegmental stenosis.OutcomeThe patient was speculated as having RCVS and was treated with oral lomerizine hydrochloride. Repeat MRA and BPAS-MRI 2 months later showed resolution, confirming RCVS.ConclusionCombined with MRA, BPAS-MRI is an effective and non-invasive imaging method for diagnosis of RCVS of the basilar artery.Early and accurate diagnosis of RCVS is of utmost important for appropriate management and prognosis. BPAS-MRI may have a supplementary role to MRA in the diagnosis of RCVS of the basilar artery.
      PubDate: 2017-07-28T02:40:58.753445-05:
      DOI: 10.1002/ams2.300
       
  • Management of pediatric ‘cannot intubate, cannot oxygenate’
    • Authors: Yohei Okada; Wataru Ishii, Norio Sato, Hirokazu Kotani, Ryoji Iiduka
      First page: 462
      Abstract: Case“Cannot intubate, cannot oxygenate” (CICO) is a rare, life-threatening situation. We describe a pediatric case of CICO and highlight some educational points.A 3-year-old boy who collapsed in the bathtub came to our emergency department. On admission, he went into cardiac arrest probably because of an airway obstruction. We judged his condition as CICO and carried out an emergent tracheostomy after several attempts to perform a cricothyroidotomy failed. We continued resuscitation; however, circulation did not return spontaneously.OutcomeThe child died, and the autopsy showed an airway obstruction caused by idiopathic anaphylaxis or acquired angioedema.ConclusionThis case highlights that it can be anatomically difficult to perform a percutaneous cannula cricothyroidotomy and scalpel cricothyroidotomy safely in pediatric CICO cases. An emergent tracheostomy using the scalpel–finger–bougie technique on the proximal trachea should be considered in such cases.This case highlights that it can be anatomically difficult to perform a percutaneous cannula cricothyroidotomy and scalpel cricothyroidotomy safely in pediatric Cannot Intubate, Cannot Oxygenate cases. An emergent tracheostomy using the scalpel–finger–bougie technique on the proximal trachea should be considered in such cases.
      PubDate: 2017-08-18T01:57:43.913464-05:
      DOI: 10.1002/ams2.305
       
  • Perimortem cesarean delivery and subsequent emergency hysterectomy: new
           strategy for maternal cardiac arrest
    • Authors: Mayako Goto; Hiroaki Watanabe, Kazuhide Ogita, Tetsuya Matsuoka
      First page: 467
      Abstract: CasesPerimortem cesarean delivery (PMCD) is the only way to resuscitate pregnant women in cardiac arrest, and has been found to increase maternal resuscitation rate by increasing circulating plasma volume. However, many obstetricians have not experienced a case of PMCD, as situations requiring it are rare. We report our strategy for cases of maternal cardiac arrest, on the basis of a review of published work, and present two case reports from our medical center.OutcomesIn case 1, PMCD led to death by massive bleeding. In case 2, PMCD and hysterectomy were carried out after the introduction of venoarterial extracorporeal membrane oxygenation, and both mother and baby survived.ConclusionWe find that rapid hysterectomy as a damage control surgery following PMCD can be life-saving for both mother and baby.We find that rapid hysterectomy as a damage control surgery following PMCD can be life-saving for both mother and baby.
      PubDate: 2017-08-17T23:06:04.364734-05:
      DOI: 10.1002/ams2.301
       
  • Delayed sensorimotor neuropathy and renal failure: an additional report in
           a patient with diethylene glycol poisoning
    • Authors: Hiroki Kamada; Hideaki Suzuki, Ryosuke Nomura, Shigeki Kushimoto
      First page: 472
      PubDate: 2017-07-13T23:05:35.051833-05:
      DOI: 10.1002/ams2.285
       
 
 
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