Abstract. Aim of the study was to clarify the relationship between metformin-induced vitamin B12 (B12) deficiency, hyperhomocysteinemia and vascular complications in patients with type 2 diabetes. Serum B12 concentrations, homocysteine plasma levels, the presence of retinopathy and history of macroangiopathy (stroke or coronary heart disease) were analyzed in patients without renal dysfunction (serum creatinine<115 µmol/L). Firstly, B12 status was analyzed in 62 consecutive metformin-treated patients. Secondly, the relationship between B12, homocysteine and vascular complications was analyzed in 46 metformin-treated and 38 age-and sex-matched non-metformin-treated patients. Among the 62 consecutive metformin-treated patients, B12 was deficient (<150 pmol/L) in 8 (13%) and borderline-deficient (150-220 pmol/L) in 18 (29%): the larger the metformin dosage, the lower the B12 (P=0.02, Spearman's ρ=-0.30). There were independent correlations between metformin use and B12 lowering (P = 0.02, r = -0.25), and B12 lowering and elevation of homocysteine (P<0.01, r =-0.34). Elevation of homocysteine was a risk for retinopathy (P =0.02, OR 1.26, 95%CI 1.04-1.52). There was no significant relation between homocysteine and macroangiopathy. Correlation between B12 and homocysteine was stronger in metformin-treated (P<0.01, r =-0.48) than non-metformin-treated (P=0.04, r = -0.38) patients. In ten B12 deficient patients, B12 supplementation (1,500 µg/day) for 2.2±1.0 months with continued use of metformin raised B12 levels: 152±42 and 299±97 pmol/L before and after treatment, respectively (P<0.01). Metformininduced B12 lowering in diabetes was associated with elevation of homocysteine, and hyperhomocysteinemia was independently related to retinopathy. Metformin-induced B12 deficiency was correctable with B12 supplementation.Key words: Metformin, Homocysteine, Diabetes, Retinopathy VITAMIN B12 (B12) DEFICIENCY in metformintreated patients with type 2 diabetes mellitus (T2DM) is well known [1][2][3][4][5]. The drug may interfere with the calcium-dependent absorption of B12 [6,7]. In general, B12 deficiency is a cause of hyperhomocysteinemia [8], which is a risk factor for micro-and macrovascular complications [9][10][11]. However, as far as we are aware, no systematic analysis of the status of B12, homocysteine (HC) and vascular complications in relation to metformin use has been performed in patients with T2DM. We hypothesized that metformin-induced B12 deficiency may be causing an elevation of HC in patients with T2DM, which may in turn have a deleterious effect on diabetic vascular complications. Because metformin is the first choice oral hypoglycemic agent (OHA) [12] and is prescribed in a large number of patients worldwide, the issue is a very important one. Materials and Methods ParticipantsThe study was approved by the Aizawa Hospital Review Board and written informed consent was obtained from the participants. Patients with renal dysfunction (serum creatinine ≥115 µmol/L), or a history of gastrectomy, and those receiving v...

Rationale The prevalence of burnout among critical care professionals during the coronavirus disease (COVID-19) pandemic varies in different countries. Objectives To investigate the prevalence of burnout and turnover intention in Japanese critical care professionals in March 2021. Methods This cross-sectional study used a web-based survey of Japanese critical care professionals working in 15 intensive care units in 15 prefectures. Burnout was measured using the Mini Z 2.0 Survey. Intention to leave (turnover intention) was assessed by survey. Resilience was measured using the Brief Resilience Scale (Japanese version). Demographics and personal and workplace characteristics were also collected. Results Of 1,205 critical care professionals approached, 936 (77.6%) completed the survey. Among these, 24.3%, 20.6%, and 14.2% reported symptoms of burnout, depression, and anxiety, respectively. A total of 157 respondents (16.8%) reported turnover intention. On multivariate analysis, higher resilience scores (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.84–0.95; and OR, 0.94; 95% CI, 0.91–0.96) and perceived support from the hospital (OR, 0.64; 95% CI, 0.44–0.93; and OR, 0.54; 95% CI, 0.40–0.73) were associated with a lower odds of burnout and turnover intention, respectively. Conclusions Approximately 24% and 17% of the Japanese critical care professionals surveyed had symptoms of burnout and turnover intention from critical care, respectively, during the COVID-19 pandemic. Such professionals require organizational support to cultivate both individual and organizational resilience to reduce burnout and turnover intention.

Purpose Coronavirus disease 2019 (COVID-19) has placed a great burden on critical care services worldwide. Data regarding critically ill COVID-19 patients and their demand of critical care services outside of initial COVID-19 epicenters are lacking. This study described clinical characteristics and outcomes of critically ill COVID-19 patients and the capacity of a COVID-19-dedicated intensive care unit (ICU) in Kobe, Japan. Methods This retrospective observational study included critically ill COVID-19 patients admitted to a 14-bed COVID-19-dedicated ICU in Kobe between March 3, 2020 and June 21, 2020. Clinical and daily ICU occupancy data were obtained from electrical medical records. The last follow-up day was June 28, 2020. Results Of 32 patients included, the median hospital follow-up period was 27 (interquartile range 19-50) days. The median age was 68 (57-76) years; 23 (72%) were men and 25 (78%) had at least one comorbidity. Nineteen (59%) patients received invasive mechanical ventilation for a median duration of 14 (8-27) days. Until all patients were discharged from the ICU on June 5, 2020, the median daily ICU occupancy was 50% (36-71%). As of June 28, 2020, six (19%) died during hospitalization. Of 26 (81%) survivors, 23 (72%) were discharged from the hospital and three (9%) remained in the hospital. Conclusion During the first months of the outbreak in Kobe, most critically ill patients were men aged ≥ 60 years with at least one comorbidity and on mechanical ventilation; the ICU capacity was not strained, and the case-fatality rate was 19%.

We report a case involving accidental ingestion of a marble that was detected by point-of-care ultrasonography of the abdomen with the patient in the upright and slightly forward tilting position, which we term the "bowing position." Using this position for abdominal ultrasonography may be more useful than the usual supine position for such patients.

IMPORTANCE: Despite various reports on the incidence of adverse events related to the in-hospital transport of critically ill patients, there is little verification of the correlation between the occurrence of adverse events and the use of checklists. The risk factors for the occurrence of adverse events during transport based on the use of checklists have not been well studied. Understanding them can contribute to making patient transport safer. OBJECTIVES:We aimed to investigate the frequency of adverse events and risk factors related to the in-hospital transport of critically ill patients in a hospital that uses a checklist for transporting patients.