ABSTRACT:Blunt neck trauma is an uncommon condition in sports yet life-threatening if left untreated; hence, early diagnosis and management is necessary once suspected. We report a collegiate rugby player tackled around the neck during intersquad scrimmage. He broke his cricoid and thyroid cartilage, resulting in cervical subcutaneous emphysema and pneumomediastinum and eventually, airway obstruction. Thus, he underwent cricothyroidotomy and emergency tracheotomy. After 20 d, the emphysema disappeared. However, dilation failure of the vocal cord remained, thereby requiring laryngeal reconstruction. In conclusion, blunt neck trauma can cause airway obstruction in various sports.

The aim of this study is to evaluate the usefulness of the pre-hospital National Early Warning Score (pNEWS) and the pre-hospital Modified Early Warning Score (pMEWS) for predicting admission and in-hospital mortality in elderly patients presenting to the emergency department (ED). We also compare the value of the pNEWS with that of the ED NEWS (eNEWS) and ED MEWS (eMEWS) for predicting admission and in-hospital mortality. This retrospective, single-centre observational study was carried out in the ED of Jikei University Kashiwa Hospital, in Chiba, Japan, from 1st April 2017 to 31st March 2018. All patients aged 65 years or older were included in this study. The pNEWS/eNEWS were derived from seven common physiological vital signs: respiratory rate, peripheral oxygen saturation, the presence of inhaled oxygen parameters, body temperature, systolic blood pressure, pulse rate and Alert, responds to Voice, responds to Pain, Unresponsive (AVPU) score, whereas the pMEWS/eMEWS were derived from six common physiological vital signs: respiratory rate, peripheral oxygen saturation, body temperature, systolic blood pressure, pulse rate and AVPU score. Discrimination was assessed by plotting the receiver operating characteristic (ROC) curve and calculating the area under the ROC curve (AUC). The median pNEWS, pMEWS, eNEWS and eMEWS were significantly higher at admission than at discharge (p < 0.001). The median pNEWS, pMEWS, eNEWS and eMEWS of non-survivors were significantly higher than those of the survivors (p < 0.001). The AUC for predicting admission was 0.559 for the pNEWS and 0.547 for the pMEWS. There was no significant difference between the AUCs of the pNEWS and the pMEWS for predicting admission (p = 0.102). The AUCs for predicting in-hospital mortality were 0.678 for the pNEWS and 0.652 for the pMEWS. There was no significant difference between the AUCs of the pNEWS and the pMEWS for predicting in-hospital mortality (p = 0.081). The AUC for predicting admission was 0.628 for the eNEWS and 0.591 for the eMEWS. The AUC of the eNEWS was significantly greater than that of the eMEWS for predicting admission (p < 0.001). The AUC for predicting in-hospital mortality was 0.789 for the eNEWS and 0.720 for the eMEWS. The AUC of the eNEWS was significantly greater than that of the eMEWS for predicting in-hospital mortality (p < 0.001). For admission and in-hospital mortality, the AUC of the eNEWS was significantly greater than that of the pNEWS (p < 0.001, p < 0.001), and the AUC of the eMEWS was significantly greater than that of the pMEWS (p < 0.01, p < 0.05). Our single-centre study has demonstrated the low utility of the pNEWS and the pMEWS as predictors of admission and in-hospital mortality in elderly patients, whereas the eNEWS and the eMEWS predicted admission and in-hospital mortality more accurately. Evidence from multicentre studies is needed before introducing pre-hospital versions of risk-scoring systems.

The aim of this study was to evaluate the value of the Abbreviated National Early Warning Score (aNEWS) for predicting admissions and in-hospital mortality in elderly patients present to Emergency Department (ED). This retrospective, single-centred observational study was carried out in the ED of Minamitama Hospital, in Tokyo, Japan from 1 April 2018 to 30 April 2018. All of the patients aged 65 and older were included in this study. The aNEWS is based on six common physiological vital signs, including peripheral oxygen saturation, the presence of inhaled oxygen parameters, body temperature, systolic blood pressure, pulse rate, and the Alert, responds to Voice, responds to Pain, Unresponsive score. The scores range from 0 and 3 for each parameter. The aNEWS ranged from a score of 0 to a maximum of 17. The receiver operating characteristics (ROC) analysis was used to evaluate the predictive value of the aNEWS for admission and in-hospital mortality. The median aNEWS of patients admitted to the hospital was significantly higher than that of patients discharged from the ED (P<0.001). The median aNEWS of survivors was significantly higher than that of non-survivors (P<0.001). The Areas under the ROC Curve (AUC) for predicting admission was 0.773 [95% CI 0.7142 to 0.8317, P<0.001] for the aNEWS. The AUC for predicting in-hospital mortality was 0.791 [95% CI 0.604 to 0.978, P<0.001] for the aNEWS. Our single-centred study has demonstrated the utility of the aNEWS as a predictor of patient admission and in-hospital mortality in elderly patients.

A patient was a 46-year-old man. Multiple lung tumors had been pointed out on a medical examination at age 24. He came to our hospital for further examination. Multiple liver and lung tumors were found out, and epithelioid hemangioendothelioma (EHE) derived from the liver was diagnosed by biopsy. At first we gave recombinant interleukin-2 (rIL-2) by intra-arterial and local injection and then continued it by intramuscular injection for 22 years as maintenance therapy. The tumors have regressed, with partial necrosis. EHE is a rare tumor, but we do not have a standard antitumor therapy except surgical resection. This case suggests that rIL-2 may become a new therapy for EHE. We think that the report of the long-term survival of a case of EHE in which rIL-2 treatment was effective is extremely valuable.

To the Editor, Hemodialysis patients are at high risk of developing viral hepatitis infections due to frequent vascular access and the potential exposure to infected patients and contaminated medical equipment. The prevalence of various hepatitis virus infections has been investigated in hemodialysis patients (1), and a high prevalence of hepatitis B virus (HBV) infection has been observed in hemodialysis patients (2). To prevent nosocomial transmission of HBV among hemodialysis patients and staff in hemodialysis units, it is important to detect HBV infection and also to determine the level of HBV infection in hemodialysis patients (3). We investigated hepatitis B surface antigen (HBsAg) and the antibody to hepatitis B core antigen (anti-HBc antibody), and also studied HBV infectivity using the newly developed real-time detection direct test for HBV (HBV RTD-direct) in hemodialysis patients (4). Among 262 hemodialysis patients, seven patients were positive for HBsAg, and all seven were positive for HBV-DNA detected by HBV RTD-direct (Table 1). Seventy-two patients were positive for anti-HBc antibody, and of these only seven patients were positive for HBV-DNA. Even in 27 patients who showed a high titer of antiHBc antibody, only six patients showed positive results for HBV-DNA, and these six patients also had positive HBsAg results. Compared with the association between HBsAg and positive HBV-DNA results, the correlation between anti-HBc antibody and being HBV-DNApositive was significantly weak (Table 1). Positive HBV-DNA results by the HBV RTD-direct test agreed with positive HBV-DNA results by another method to detect HBV DNA, the Amplicor HBV Monitor test (data not shown). The presence of high-titer anti-HBc antibody has been recognized as persistent HBV infection (5); therefore, it has been suggested that elimination of donor blood showing high-titer anti-HBc antibody may reduce the risk of post-transfusion hepatitis B infection (6). However, the significantly low positive rate of HBV-DNA among patients with high-titer anti-HBc antibody in our study challenged the role of anti-HBc antibody as the marker for HBV infectivity. Chaudhuri et al. also evaluated serological screening of blood donors and revealed a lack of correlation between the anti-HBc antibody titer and polymerase chain reaction (PCR)-amplified HBV DNA, supporting our hypothesis (7). The HBV RTD-direct is a highly sensitive quantitative test, combining HBVDNA extraction and magnetic beads coated with polyclonal anti-HBs antigen, for the detection of HBV-DNA (4). The HBV RTD-direct test has been also reported to have a good correlation with results by conventional methods, the transcription-mediated amplification-hybridization protection assay (R = 0.941) and theAmplicor HBV Monitor test (R = 0.94) (4). In our study, an agreement between the HBV RTD-direct test and the Amplicor HBV Monitor test was also obtained. The HBV RTD-direct test can extract DNA from infectious viral particles without TABLE 1. Correlation between serological HBV markers and HBV-DNA