Publications by authors named "Junichi Sasaki"

135 Publications

Perioperative clinical parameters associated with short-term mortality after colorectal perforation.

Eur J Trauma Emerg Surg 2021 Jun 3. Epub 2021 Jun 3.

Department of Surgery, Saiseikai Utsunomiya Hospital, 911-1 Takebayashi-cho, Utsunomiya, Tochigi, 321-0974, Japan.

Purpose: Although early prediction of mortality is useful for the management of patients with colorectal perforations, no significant perioperative predictive factors have been identified. The purpose of this study was to identify useful prognostic factors for patients with colorectal perforation.

Methods: This single-center retrospective study included consecutive patients undergoing emergency surgery for colorectal perforation from January 2012 to December 2019. The primary outcome was combined 30 day and in-hospital mortality. Patient- and disease-related factors obtained perioperatively were evaluated for mortality prediction. A scoring system was developed to enhance clinical utility.

Results: Overall, 146 patients were included and 20 (14%) died after surgery. Multivariate logistic regression identified five predictive factors: age, hemodialysis, uncommon perforation etiology, plasma albumin level, and decreased platelet count. The area under the receiver operating curve for the scoring system using these parameters was 0.894 (95% CI 0.835-0.952). Patients at high-risk of mortality were classified by the proposed score with a sensitivity of 90.0% and negative predictive value of 98.0%.

Conclusion: This study identified five perioperative factors significantly associated with mortality of patients with colorectal perforation. Although these parameters predict mortality of patients with colorectal perforation using a score with high discrimination, further study is required to confirm these findings.
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http://dx.doi.org/10.1007/s00068-021-01719-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8172362PMC
June 2021

Antithrombotic drugs have a minimal effect on intraoperative blood loss during emergency surgery for generalized peritonitis: a nationwide retrospective cohort study in Japan.

World J Emerg Surg 2021 May 27;16(1):27. Epub 2021 May 27.

Department of Emergency and Critical Care Medicine, School of Medicine, Keio University, 35 Shinanomachi, Shinkjuku, Tokyo, 164-8582, Japan.

Background: The effect of antithrombotic drugs on intraoperative operative blood loss volume in patients undergoing emergency surgery for generalized peritonitis is not well defined. The purpose of this study was to investigate the effect of antithrombotic drugs on intraoperative blood loss in patients with generalized peritonitis using a nationwide surgical registry in Japan.

Method: This retrospective cohort study used a nationwide surgical registry data from 2011 to 2017 in Japan. Propensity score matching for the use of antithrombotic drugs was used for the adjustment of age, gender, comorbidities, frailty, preoperative state, types of surgery, surgical approach, laboratory data, and others. The main outcome was intraoperative blood loss: comparison of intraoperative blood loss, ratio of intraoperative blood loss after adjusted for confounding factors, and variable importance of all covariates.

Results: A total of 70,105 of the eligible 75,666 patients were included in this study, and 2947 patients were taking antithrombotic drugs. Propensity score matching yielded 2864 well-balanced pairs. The blood loss volume was slightly higher in the antithrombotic drug group (100 [10-349] vs 70 [10-299] ml). After adjustment for confounding factors, the use of antithrombotic drugs was related to a 1.30-fold increase in intraoperative blood loss compared to non-use of antithrombotic drugs (95% CI, 1.16-1.45). The variable importance revealed that the effect of the use of antithrombotic drugs was minimal compared with surgical approach or type of surgery.

Conclusion: This study shows that while taking antithrombotic drugs is associated with a slight increase in intraoperative blood loss in patients undergoing emergency surgery for generalized peritonitis, the effect is likely of minimal clinical significance.
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http://dx.doi.org/10.1186/s13017-021-00374-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8162009PMC
May 2021

Disseminated intravascular coagulation immediately after trauma predicts a poor prognosis in severely injured patients.

Sci Rep 2021 May 26;11(1):11031. Epub 2021 May 26.

Trauma and Acute Critical Care Center, Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan.

Trauma patients die from massive bleeding due to disseminated intravascular coagulation (DIC) with a fibrinolytic phenotype in the early phase, which transforms to DIC with a thrombotic phenotype in the late phase of trauma, contributing to the development of multiple organ dysfunction syndrome (MODS) and a consequently poor outcome. This is a sub-analysis of a multicenter prospective descriptive cross-sectional study on DIC to evaluate the effect of a DIC diagnosis on the survival probability and predictive performance of DIC scores for massive transfusion, MODS, and hospital death in severely injured trauma patients. A DIC diagnosis on admission was associated with a lower survival probability (Log Rank P < 0.001), higher frequency of massive transfusion and MODS and a higher mortality rate than no such diagnosis. The DIC scores at 0 and 3 h significantly predicted massive transfusion, MODS, and hospital death. Markers of thrombin and plasmin generation and fibrinolysis inhibition also showed a good predictive ability for these three items. In conclusion, a DIC diagnosis on admission was associated with a low survival probability. DIC scores obtained immediately after trauma predicted a poor prognosis of severely injured trauma patients.
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http://dx.doi.org/10.1038/s41598-021-90492-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8154895PMC
May 2021

Reply to Swinging the pendulum in prehospital trauma mortality needs a more holistic approach.

J Trauma Acute Care Surg 2021 May 25. Epub 2021 May 25.

Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan, Department of Emergency Medicine, Tokyo Dental College, Ichikawa General Hospital, Chiba, Japan, Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan,

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http://dx.doi.org/10.1097/TA.0000000000003292DOI Listing
May 2021

The interplay between bystander cardiopulmonary resuscitation and ambient temperature on neurological outcome after cardiac arrest: A nationwide observational cohort study.

Resuscitation 2021 May 20;164:46-53. Epub 2021 May 20.

Laboratory for Critical Care Physiology, Feinstein Institutes for Medical Research, Northwell Health System, Manhasset, NY, USA; Department of Emergency Medicine, North Shore University Hospital, Northwell Health System, Manhasset, NY, USA; Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.

Background: At lower ambient temperature, patients with out-of-hospital cardiac arrest (OHCA) easily experience hypothermia. Hypothermia has shown to improve the rate of successful return of spontaneous circulation (ROSC) in animal models. We hypothesized that lower temperature affects the impact of bystander cardiopulmonary resuscitation (CPR) on the increased odds of a favorable neurological outcome post-OHCA.

Methods: This study used information collected by the prospective, nationwide, Utstein registry to examine data from 352,689 adult patients who experienced OHCA from 2012 to 2016 in Japan. The primary outcome was a 1-month favorable neurological outcomes. Multivariable logistic regression analyses were conducted to test the impact of bystander CPR according to the temperature on the favorable outcome.

Results: A total of 201,111 patients with OHCA were included in the complete case analysis. The lower temperature group had lower proportions of receiving bystander CPR (46.5 vs. 47.9%) and having favorable outcome (2.1 vs 2.8%) than those in the higher group. Multivariable analysis revealed that bystander CPR at lower temperatures was significantly associated with favorable outcomes (adjusted odds ratio, 1.22; 95% CI, 1.09-1.37), whereas bystander CPR at higher temperatures was not associated with favorable outcomes (1.02; 0.92-1.13). The nonlinear relationship using a spline curve in the multivariable model revealed that odds ratio of favorable neurological outcomes associated with bystander CPR increased as the temperature decreased.

Conclusion: Bystander CPR was associated with favorable neurological outcomes at lower temperatures. The odds of a favorable outcome associated with bystander CPR increased as the temperature decreased.
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http://dx.doi.org/10.1016/j.resuscitation.2021.05.008DOI Listing
May 2021

The Japanese Medical Science Federation COVID-19 Expert Opinion English Version.

JMA J 2021 Apr 8;4(2):148-162. Epub 2021 Apr 8.

Japanese Society of Respiratory Care Medicine.

In 2020, the COVID-19 pandemic has had unprecedented impacts on various aspects of the world. Each academic society has published a guide and/or guidelines on how to cope with COVID-19 separately. As the one and only nationwide association of academic societies that represent medical science in Japan, JMSF has decided to publish the expert opinion to help patients and care providers find specifically what they want. This expert opinion is a summary of recommendations by many academic societies and will be updated when necessary. Patients that each academic society targets differ even though they suffer from the same COVID-19, and recommendations can be different in a context-dependent manner. Readers are supposed to be flexible and adjustable when they use this expert opinion.
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http://dx.doi.org/10.31662/jmaj.2021-0002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8118966PMC
April 2021

Incidence and Impact of Dysglycemia in Patients with Sepsis Under Moderate Glycemic Control.

Shock 2021 May 11. Epub 2021 May 11.

Center for General Medicine Education, School of Medicine, Keio University, Japan Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Japan Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Japan Division of Traumatology, Research Institute, National Defense Medical College, Japan Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Japan Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Japan Department of General Medicine, Juntendo University, Japan Health Services Research and Development Center, University of Tsukuba, Japan Emergency and Trauma Center, Kameda Medical Center, Japan Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Japan Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Japan Division of Disaster and Emergency Medicine, Department of Surgery Related, Kobe University Graduate School of Medicine, Japan Advanced Critical Care Center, Aichi Medical University Hospital, Japan Advanced Medical Emergency & Critical Care Center, Yamaguchi University Hospital, Japan Emergency & Critical Care Center, Kawasaki Municipal Hospital, Japan Department of Emergency & Critical Care Medicine, School of Medicine, Kurume University, Japan Department of Emergency and Critical Care Medicine, Aizu Chuo Hospital, Japan Department of Emergency Medicine, Trauma and Resuscitation Center, Teikyo University School of Medicine Department of Acute Medicine, Kawasaki Medical School, Japan Department of Trauma and Critical Care Medicine, Kyorin University School of Medicine, Japan Department of Emergency and Critical Care Medicine Chiba University Graduate School of Medicine, Japan Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Japan (new) Trauma and Acute Critical Care Center, Medical Hospital, Tokyo Medical and Dental University, Japan Department of Surgery, Center for Gastroenterology and Liver Disease, Kitakyushu City Yahata Hospital, Japan Emergency and Critical Care Medicine, Saga University Hospital, Japan Center Hospital of the National Center for Global Health and Medicine, Japan Department of Emergency and Critical Care Medicine, Nippon Medical School, Japan Department of Trauma, Critical Care Medicine, and Burn Center, Japan Community Healthcare Organization, Chukyo Hospital, Japan Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Japan.

Abstract: Glycemic control strategies for sepsis have changed significantly over the last decade, but their impact on dysglycemia and its associated outcomes has been poorly understood. In addition, there is controversy regarding the detrimental effects of hyperglycemia in sepsis. To evaluate the incidence and risks of dysglycemia under current strategy, we conducted a preplanned subanalysis of the sepsis cohort in a prospective, multicenter FORECAST study. A total of 1,140 patients with severe sepsis, including 259 patients with pre-existing diabetes, were included. Median blood glucose levels were approximately 140 mg/dL at 0 h and 72 h indicating that blood glucose was moderately controlled. The rate of initial and late hyperglycemia was 27.3% and 21.7%, respectively. The rate of early hypoglycemic episodes during the initial 24 h was 13.2%. Glycemic control was accompanied by a higher percentage of initial and late hyperglycemia but not with early hypoglycemic episodes, suggesting that glycemic control was targeted at excess hyperglycemia. In nondiabetic patients, late hyperglycemia (hazard ratio, 95% confidence interval; p-value: 1.816, 1.116-2.955, 0.016) and early hypoglycemic episodes (1.936, 1.180-3.175, 0.009) were positively associated with in-hospital mortality. Further subgroup analysis suggested that late hyperglycemia and early hypoglycemic episodes independently, and probably synergistically, affect the outcomes. In diabetic patients, however, these correlations were not observed. In conclusion, a significantly high incidence of dysglycemia was observed in our sepsis cohort under moderate glycemic control. Late hyperglycemia in addition to early hypoglycemia was associated with poor outcomes at least in nondiabetic patients. More sophisticated approaches are necessary to reduce the incidence of these serious complications.
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http://dx.doi.org/10.1097/SHK.0000000000001794DOI Listing
May 2021

Accuracy for Mortality Prediction With Additive Biomarkers Including Interleukin-6 in Critically Ill Patients: A Multicenter Prospective Observational Study.

Crit Care Explor 2021 Apr 26;3(4):e0387. Epub 2021 Apr 26.

Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan.

Objectives: Several inflammation markers have been reported to be associated with unfavorable clinical outcomes in critically ill patients. We aimed to elucidate whether serum interleukin-6 concentration considered with Sequential Organ Failure Assessment score can better predict mortality in critically ill patients.

Design: A prospective observational study.

Setting: Five university hospitals in 2016-2018.

Patients: Critically ill adult patients who met greater than or equal to two systemic inflammatory response syndrome criteria at admission were included, and those who died or were discharged within 48 hours were excluded.

Interventions: Inflammatory biomarkers including interleukin (interleukin)-6, -8, and -10; tumor necrosis factor-α; C-reactive protein; and procalcitonin were blindly measured daily for 3 days. Area under the receiver operating characteristic curve for Sequential Organ Failure Assessment score at day 2 according to 28-day mortality was calculated as baseline. Combination models of Sequential Organ Failure Assessment score and additional biomarkers were developed using logistic regression, and area under the receiver operating characteristic curve calculated in each model was compared with the baseline.

Measurements And Main Results: Among 161 patients included in the study, 18 (11.2%) did not survive at day 28. Univariate analysis for each biomarker identified that the interleukin-6 (days 1-3), interleukin-8 (days 0-3), and interleukin-10 (days 1-3) were higher in nonsurvivors than in survivors. Analyses of 28-day mortality prediction by a single biomarker showed interleukin-6, -8, and -10 at days 1-3 had a significant discrimination power, and the interleukin-6 at day 3 had the highest area under the receiver operating characteristic curve (0.766 [0.656-0.876]). The baseline area under the receiver operating characteristic curve for Sequential Organ Failure Assessment score predicting 28-day mortality was 0.776 (0.672-0.880). The combination model using additional interleukin-6 at day 3 had higher area under the receiver operating characteristic curve than baseline (area under the receiver operating characteristic curve = 0.844, area under the receiver operating characteristic curve improvement = 0.068 [0.002-0.133]), whereas other biomarkers did not improve accuracy in predicting 28-day mortality.

Conclusions: Accuracy for 28-day mortality prediction was improved by adding serum interleukin-6 concentration to Sequential Organ Failure Assessment score.
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http://dx.doi.org/10.1097/CCE.0000000000000387DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8078448PMC
April 2021

Hyperoxemia during resuscitation of trauma patients and increased intensive care unit length of stay: inverse probability of treatment weighting analysis.

World J Emerg Surg 2021 Apr 29;16(1):19. Epub 2021 Apr 29.

Trauma and Acute Critical Care Center, Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan.

Background: Information on hyperoxemia among patients with trauma has been limited, other than traumatic brain injuries. This study aimed to elucidate whether hyperoxemia during resuscitation of patients with trauma was associated with unfavorable outcomes.

Methods: A post hoc analysis of a prospective observational study was carried out at 39 tertiary hospitals in 2016-2018 in adult patients with trauma and injury severity score (ISS) of > 15. Hyperoxemia during resuscitation was defined as PaO of ≥ 300 mmHg on hospital arrival and/or 3 h after arrival. Intensive care unit (ICU)-free days were compared between patients with and without hyperoxemia. An inverse probability of treatment weighting (IPW) analysis was conducted to adjust patient characteristics including age, injury mechanism, comorbidities, vital signs on presentation, chest injury severity, and ISS. Analyses were stratified with intubation status at the emergency department (ED). The association between biomarkers and ICU length of stay were then analyzed with multivariate models.

Results: Among 295 severely injured trauma patients registered, 240 were eligible for analysis. Patients in the hyperoxemia group (n = 58) had shorter ICU-free days than those in the non-hyperoxemia group [17 (10-21) vs 23 (16-26), p < 0.001]. IPW analysis revealed the association between hyperoxemia and prolonged ICU stay among patients not intubated at the ED [ICU-free days = 16 (12-22) vs 23 (19-26), p = 0.004], but not among those intubated at the ED [18 (9-20) vs 15 (8-23), p = 0.777]. In the hyperoxemia group, high inflammatory markers such as soluble RAGE and HMGB-1, as well as low lung-protective proteins such as surfactant protein D and Clara cell secretory protein, were associated with prolonged ICU stay.

Conclusions: Hyperoxemia until 3 h after hospital arrival was associated with prolonged ICU stay among severely injured trauma patients not intubated at the ED.

Trial Registration: UMIN-CTR, UMIN000019588 . Registered on November 15, 2015.
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http://dx.doi.org/10.1186/s13017-021-00363-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8082221PMC
April 2021

COVID-19 shares clinical features with anti-melanoma differentiation-associated protein 5 positive dermatomyositis and adult Still's disease.

Clin Exp Rheumatol 2021 May-Jun;39(3):631-638. Epub 2021 Apr 8.

Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan.

Objectives: To investigate the similarities and differences between Coronavirus disease 2019 (COVID-19) and autoimmune and autoinflammatory rheumatic diseases characterised by hyperferritinaemia, such as antimelanoma differentiation-associated protein 5 (MDA5) autoantibody-positive dermatomyositis and adult Still's disease.

Methods: We reviewed consecutive, newly diagnosed, untreated patients with COVID-19, anti-MDA5 dermatomyositis, or adult Still's disease. We compared their clinical, laboratory, and radiological characteristics, including the prevalence of macrophage activation syndrome and lung involvement in each disease.

Results: The numbers of patients with COVID-19, anti-MDA5 dermatomyositis, and adult-onset Still's disease with hyperferritinaemia (serum ferritin ≥500ng/dL) who were included for main analysis were 22, 14, and 59, respectively. COVID-19 and adult Still's disease both featured hyperinflammatory status, such as high fever and elevated serum C-reactive protein, whereas COVID-19 and anti-MDA5 dermatomyositis both presented with severe interstitial lung disease and hypoxaemia. While two-thirds of the patients in each group met the criteria for macrophage-activated syndrome that is used in systemic juvenile idiopathic arthritis, the HScore, an indicator of haemophagocytic lymphohistiocytosis, was low in anti-MDA5 dermatomyositis and COVID-19 even in severe or critical cases. The findings of chest computed tomography were similar between COVID-19 and anti-MDA5 dermatomyositis.

Conclusions: COVID-19 shared clinical features with rheumatic diseases characterised by hyperferritinaemia, including anti-MDA5 dermatomyositis and adult Still's disease. These findings should be investigated further in order to shed light on the pathogenesis of not only COVID-19 but also the aforementioned rheumatic diseases.
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May 2021

Physician-Staffed Ambulance and Increased In-Hospital Mortality of Hypotensive Trauma Patients Following Prolonged Prehospital Stay: A Nationwide Study.

J Trauma Acute Care Surg 2021 Apr 12. Epub 2021 Apr 12.

Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan Department of Emergency Medicine, Tokyo Dental College, Ichikawa General Hospital, Chiba, Japan Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan.

Background: The benefits of physician-staffed emergency medical services (EMS) for trauma patients remain unclear due to conflicting results on survival. Some studies suggested potential delays in definitive hemostasis due to prolonged prehospital stay when physicians are dispatched to the scene. We examined hypotensive trauma patients who were transported by ambulance, with the hypothesis that physician-staffed ambulances would be associated with increased inhospital mortality, compared with EMS-personnel-staffed ambulances.

Methods: A retrospective cohort study that included hypotensive trauma patients (systolic blood pressure [sBP] ≤ 90 mmHg at the scene) transported by ambulance was conducted using the Japan Trauma Data Bank (2004-2019). Physician-staffed ambulances are capable of resuscitative procedures, such as thoracotomy and surgical airway management, while EMS-personnel-staffed ambulances could only provide advanced life support. In-hospital mortality and prehospital time until the hospital arrival were compared between patients who were classified based on the type of ambulance. Inverse probability weighting was conducted to adjust baseline characteristics including age, sex, comorbidities, mechanism of injury, vital signs at the scene, injury severity, and ambulance dispatch time.

Results: Among 14,652 patients eligible for the study, 738 were transported by a physicianstaffed ambulance. In-hospital mortality was higher in the physician-staffed ambulance than in the EMS-personnel-staffed ambulance (291/738 [28.8%] vs 2287/13,090 [17.5%]; odds ratio [OR] 1.90 [1.61-2.26]; adjusted OR 1.18 [1.10-1.26]; p < 0.01), and the physician-staffed ambulance showed longer prehospital time (50 [36-66] vs 37 [29-48] min, difference = 12 [11-12] min, p < 0.01). Such potential harm of the physician-staffed ambulance was only observed among patients who arrived at the hospital with persistent hypotension (sBP < 90 mmHg on hospital arrival) in subgroup analyses.

Conclusions: Physician-staffed ambulances were associated with prolonged prehospital stay and increased in-hospital mortality among hypotensive trauma patients compared with EMSpersonnel-staffed ambulance.

Level Of Evidence: level III, therapeutic.
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http://dx.doi.org/10.1097/TA.0000000000003239DOI Listing
April 2021

Quick sequential organ failure assessment versus systemic inflammatory response syndrome criteria for emergency department patients with suspected infection.

Sci Rep 2021 Mar 5;11(1):5347. Epub 2021 Mar 5.

Medical Center for Emergency, Yamagata Prefectural Central Hospital, Yamagata, Japan.

Previous studies have shown inconsistent prognostic accuracy for mortality with both quick sequential organ failure assessment (qSOFA) and the systemic inflammatory response syndrome (SIRS) criteria. We aimed to validate the accuracy of qSOFA and the SIRS criteria for predicting in-hospital mortality in patients with suspected infection in the emergency department. A prospective study was conducted including participants with suspected infection who were hospitalised or died in 34 emergency departments in Japan. Prognostic accuracy of qSOFA and SIRS criteria for in-hospital mortality was assessed by the area under the receiver operating characteristic (AUROC) curve. Of the 1060 participants, 402 (37.9%) and 915 (86.3%) had qSOFA ≥ 2 and SIRS criteria ≥ 2 (given thresholds), respectively, and there were 157 (14.8%) in-hospital deaths. Greater accuracy for in-hospital mortality was shown with qSOFA than with the SIRS criteria (AUROC: 0.64 versus 0.52, difference + 0.13, 95% CI [+ 0.07, + 0.18]). Sensitivity and specificity for predicting in-hospital mortality at the given thresholds were 0.55 and 0.65 based on qSOFA and 0.88 and 0.14 based on SIRS criteria, respectively. To predict in-hospital mortality in patients visiting to the emergency department with suspected infection, qSOFA was demonstrated to be modestly more accurate than the SIRS criteria albeit insufficiently sensitive.Clinical Trial Registration: The study was pre-registered in the University Hospital Medical Information Network Clinical Trials Registry (UMIN000027258).
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http://dx.doi.org/10.1038/s41598-021-84743-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7935946PMC
March 2021

Predictors of severe sepsis-related in-hospital mortality based on a multicenter cohort study: The Focused Outcomes Research in Emergency Care in Acute Respiratory Distress Syndrome, Sepsis, and Trauma study.

Medicine (Baltimore) 2021 Feb;100(8):e24844

Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine.

Abstract: This study aimed to identify prognostic factors for severe sepsis-related in-hospital mortality using the structural equation model (SEM) analysis with statistical causality. Sepsis data from the Focused Outcomes Research in Emergency Care in Acute Respiratory Distress Syndrome, Sepsis, and Trauma study (FORECAST), a multicenter cohort study, was used. Forty seven observed variables from the database were used to construct 4 latent variables. SEM analysis was performed on these latent variables to analyze the statistical causality among these data. This study evaluated whether the variables had an effect on in-hospital mortality. Overall, 1148 patients were enrolled. The SEM analysis showed that the 72-hour physical condition was the strongest latent variable affecting mortality, followed by physical condition before treatment. Furthermore, the 72-hour physical condition and the physical condition before treatment strongly influenced the Sequential Organ Failure Assessment (SOFA) score with path coefficients of 0.954 and 0.845, respectively. The SOFA score was the strongest variable that affected mortality after the onset of severe sepsis. The score remains the most robust prognostic factor and can facilitate appropriate policy development on care.
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http://dx.doi.org/10.1097/MD.0000000000024844DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7909210PMC
February 2021

The real-time reverse transcription-polymerase chain reaction threshold cycle values for severe acute respiratory syndrome coronavirus 2 predict the prognosis of coronavirus disease 2019 pneumonia.

Respir Investig 2021 May 28;59(3):360-363. Epub 2021 Jan 28.

Keio University School of Medicine, Shinjuku, Tokyo, Japan.

The clinical course of coronavirus disease 2019 (COVID-19) varies from mild to critical. We retrospectively examined whether clinical and laboratory findings on admission could predict COVID-19 prognosis. Among various factors associated with COVID-19 severity, our results indicated that the real-time reverse transcription-polymerase chain reaction (RT-PCR) threshold cycle (Ct) values for severe acute respiratory syndrome coronavirus 2 were the most useful predictor of COVID-19 prognosis.
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http://dx.doi.org/10.1016/j.resinv.2020.12.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7843124PMC
May 2021

Medicine at mass gatherings: current progress of preparedness of emergency medical services and disaster medical response during 2020 Tokyo Olympic and Paralympic Games from the perspective of the Academic Consortium (AC2020).

Acute Med Surg 2021 Jan-Dec;8(1):e626. Epub 2021 Feb 2.

Japan Pediatric Society Tokyo Japan.

Mass gatherings are events characterized by "the concentration of people at a specific location for a specific purpose over a set period of time that have the potential to strain the planning and response resources of the host country or community." Previous reports showed that, as a result of the concentration of people in the limited area, injury and illness occurred due to several factors. The response plan should aim to provide timely medical care to the patients and to reduce the burden on emergency hospitals, and to maintain a daily emergency medical services system for residents of the local area. Although a mass gathering event will place a significant burden on the local health-care system, it can provide the opportunity for long-term benefits of public health-care and improvement of daily medical service systems after the end of the event. The next Olympic and Paralympic Games will be held in Tokyo, during which mass gatherings will occur on a daily basis in the context of the coronavirus disease (COVID-19) epidemic. The Academic Consortium on Emergency Medical Services and Disaster Medical Response Plan during the Tokyo Olympic and Paralympic Games in 2020 (AC2020) was launched 2016, consisting of 28 academic societies in Japan, it has released statements based on assessments of medical risk and publishing guidelines and manuals on its website. This paper outlines the issues and countermeasures for emergency and disaster medical care related to the holding of this big event, focusing on the activities of the academic consortium.
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http://dx.doi.org/10.1002/ams2.626DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7852170PMC
February 2021

Association between low body mass index and increased 28-day mortality of severe sepsis in Japanese cohorts.

Sci Rep 2021 Jan 15;11(1):1615. Epub 2021 Jan 15.

Department of Trauma, Critical Care Medicine, and Burn Center, Japan Community Healthcare Organization Chukyo Hospital, Nagoya, Japan.

Current research regarding the association between body mass index (BMI) and altered clinical outcomes of sepsis in Asian populations is insufficient. We investigated the association between BMI and clinical outcomes using two Japanese cohorts of severe sepsis (derivation cohort, Chiba University Hospital, n = 614; validation cohort, multicenter cohort, n = 1561). Participants were categorized into the underweight (BMI < 18.5) and non-underweight (BMI ≥ 18.5) groups. The primary outcome was 28-day mortality. Univariate analysis of the derivation cohort indicated increased 28-day mortality trend in the underweight group compared to the non-underweight group (underweight 24.4% [20/82 cases] vs. non-underweight 16.0% [85/532 cases]; p = 0.060). In the primary analysis, multivariate analysis adjusted for baseline imbalance revealed that patients in the underweight group had a significantly increased 28-day mortality compared to those in the non-underweight group (p = 0.031, adjusted odds ratio [OR] 1.91, 95% confidence interval [CI] 1.06-3.46). In a repeated analysis using a multicenter validation cohort (underweight n = 343, non-underweight n = 1218), patients in the underweight group had a significantly increased 28-day mortality compared to those in the non-underweight group (p = 0.045, OR 1.40, 95% CI 1.00-1.97). In conclusion, patients with a BMI < 18.5 had a significantly increased 28-day mortality compared to those with a BMI ≥ 18.5 in Japanese cohorts with severe sepsis.
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http://dx.doi.org/10.1038/s41598-020-80284-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7810989PMC
January 2021

Infected abdominal aorta aneurysm secondary to streptococcal toxic shock syndrome due to : a case report from Japan.

Acute Med Surg 2020 Jan-Dec;7(1):e617. Epub 2020 Dec 20.

Department of Emergency and Critical Care Medicine Keio University School of Medicine Tokyo Japan.

Background: Infected aortic aneurysm secondary to streptococcal toxic shock syndrome caused by is uncommon and associated with high mortality.

Case Presentation: A 75-year-old man with metastatic lung cancer and an abdominal aortic aneurysm presented with high fever for 3 days. He was diagnosed with septic shock and was admitted to our hospital. The blood culture was positive for , and streptococcal toxic shock syndrome was diagnosed. During treatment, enhanced computed tomography revealed an increase in the size of the abdominal aortic aneurysm, leading to the diagnosis of an infected aortic aneurysm. Replacement of the aneurysm with a synthetic graft was carried out successfully. The patient gradually recovered after the surgery.

Conclusion: We successfully managed an infected aortic aneurysm secondary to streptococcal toxic shock syndrome. Infected aortic aneurysms should be considered in patients with a medical history of aortic aneurysms and presenting with streptococcal toxic shock syndrome.
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http://dx.doi.org/10.1002/ams2.617DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7750026PMC
December 2020

Checklist for infection control in the emergency department.

Acute Med Surg 2020 Jan-Dec;7(1):e540. Epub 2020 Sep 3.

National Hospital Organization Kumamoto Medical Center Kumamoto Japan.

The risk of encountering human-to-human infections, including emerging infectious diseases, should be adequately and appropriately addressed in the emergency department. However, guidelines based on sufficient evidence on infection control in the emergency department have not been developed anywhere in the world. Each facility examines and implements its own countermeasures. The Japanese Association for Acute Medicine has established the "Committee for Infection Control in the Emergency Department" in cooperation with the Japanese Association for Infectious Diseases, Japanese Society for Infection Prevention and Control, Japanese Society for Emergency Medicine, and Japanese Society for Clinical Microbiology. A joint working group has been established to consider appropriate measures. This group undertook a comprehensive and multifaceted review of infection control measures for emergency outpatients and related matters, and released a checklist for infection control in emergency departments. This checklist has been prepared such that even small emergency departments with few or no emergency physicians can control infection by following the checklist, without committing any major errors. The checklist includes a control system for infection control, education, screening, and vaccination, prompt response to suspected infections, and management of the risk of infection in facilities. In addition, the timing of the check and interval at which the check is carried out are specified as categories. We hope that this checklist will contribute to improving infection control in the emergency department.
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http://dx.doi.org/10.1002/ams2.540DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7751486PMC
September 2020

The provisional extension to induce complete attachment technique is associated with abdominal aortic remodeling and reduces aorta-related adverse events after aortic dissection.

J Vasc Surg 2020 Dec 16. Epub 2020 Dec 16.

Department of Cardiovascular Surgery, School of Medicine, Keio University, Tokyo, Japan.

Objective: This study evaluated the efficacy of the provisional extension to induce complete attachment (PETTICOAT) technique for type B and postoperative residual type B aortic dissections compared with the conventional thoracic endovascular aortic repair (TEVAR) technique.

Methods: In this retrospective study, we compared sequential aortic morphologic changes in consecutive patients with type B and postoperative residual type B aortic dissections treated with the PETTICOAT technique between January 2016 and December 2017 with patients treated with the conventional TEVAR between January 2013 and December 2015. Outcomes included aortic remodeling and aorta-related adverse events for 2 years postoperatively.

Results: Forty-eight patients were included in this study (24 in the PETTICOAT group, 24 patients in the conventional TEVAR group). Although both groups showed aortic remodeling in the descending thoracic aorta, the PETTICOAT group developed significantly better aortic remodeling in the abdominal aorta compared with the conventional TEVAR group during the observation period. The PETTICOAT group had significantly fewer aorta-related adverse events compared with the conventional TEVAR group (8% vs 54%; P < .001). Aorta-related adverse events more commonly occurred in the poor remodeling group compared with in the good remodeling group (P = .001; hazard ratio, 8.32; 95% confidence interval, 2.26-30.64).

Conclusions: This study suggests that the PETTICOAT technique for aortic dissection may promote aortic remodeling and decrease the incidence of aorta-related adverse events. Additional studies are required to confirm these preliminary findings.
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http://dx.doi.org/10.1016/j.jvs.2020.11.038DOI Listing
December 2020

Dermal fibroblast-like cells reprogrammed directly from adipocytes in mouse.

Sci Rep 2020 12 8;10(1):21467. Epub 2020 Dec 8.

Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.

In deep burns, early wound closure is important for healing, and skin grafting is mainly used for wound closure. However, it is difficult to achieve early wound closure in extensive total body surface area deep burns due to the lack of donor sites. Dermal fibroblasts, responsible for dermis formation, may be lost in deep burns. However, fat layers composed of adipocytes, lying underneath the dermis, are retained even in such cases. Direct reprogramming is a novel method for directly reprograming some cells into other types by introducing specific master regulators; it has exhibited appreciable success in various fields. In this study, we aimed to assess whether the transfection of master regulators (ELF4, FOXC2, FOXO1, IRF1, PRRX1, and ZEB1) could reprogram mouse adipocytes into dermal fibroblast-like cells. Our results indicated the shrinkage of fat droplets in reprogrammed mouse adipocytes and their transformation into spindle-shaped dermal fibroblasts. Reduced expression of PPAR-2, c/EBP, aP2, and leptin, the known markers of adipocytes, in RT-PCR, and enhanced expression of anti-ER-TR7, the known anti-fibroblast marker, in immunocytochemistry, were confirmed in the reprogrammed mouse adipocytes. The dermal fibroblast-like cells, reported here, may open up a new treatment mode for enabling early closure of deep burn wounds.
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http://dx.doi.org/10.1038/s41598-020-78523-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7722719PMC
December 2020

Reply to Methodological issues on developing a novel scale for prediction of delayed intubation in patients with inhalation injury.

Burns 2021 02 27;47(1):258. Epub 2020 Apr 27.

Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan.

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http://dx.doi.org/10.1016/j.burns.2020.04.008DOI Listing
February 2021

Daily inhalation of hydrogen gas has a blood pressure-lowering effect in a rat model of hypertension.

Sci Rep 2020 11 26;10(1):20173. Epub 2020 Nov 26.

Department of Basic Science, Nippon Veterinary and Life Science University, School of Veterinary Nursing and Technology, Tokyo, 180-8602, Japan.

A recent clinical study demonstrated that haemodialysis with a dialysate containing hydrogen (H) improves blood pressure control in end-stage kidney disease. Herein, we examined whether H has a salutary effect on hypertension in animal models. We subjected 5/6 nephrectomised rats to inhalation of either H (1.3% H + 21% O + 77.7% N) or control (21% O + 79% N) gas mixture for 1 h per day. H significantly suppressed increases in blood pressure after 5/6 nephrectomy. The anti-hypertensive effect of H was also confirmed in rats in a stable hypertensive state 3 weeks after nephrectomy. To examine the detailed effects of H on hypertension, we used an implanted telemetry system to continuously monitor blood pressure. H exerted an anti-hypertensive effect not only during daytime rest, but also during night-time activities. Spectral analysis of blood pressure variability revealed that H improved autonomic imbalance, namely by suppressing the overly active sympathetic nervous system and augmenting parasympathetic nervous system activity; these effects co-occurred with the blood pressure-lowering effect. In conclusion, 1-h daily exposure to H exerts an anti-hypertensive effect in an animal model of hypertension.
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http://dx.doi.org/10.1038/s41598-020-77349-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7692487PMC
November 2020

Current spectrum of causative pathogens in sepsis: A prospective nationwide cohort study in Japan.

Int J Infect Dis 2021 Feb 19;103:343-351. Epub 2020 Nov 19.

Department of Anesthesiology and Critical Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan; Department of Acute and Critical Care Medicine, Sapporo Tokushukai Hospital, Higashi, Sapporo, Hokkaido, Japan. Electronic address:

Background: There is no one-size-fits-all empiric antimicrobial therapy for sepsis because the pathogens vary according to the site of infection and have changed over time. Therefore, updating knowledge on the spectrum of pathogens is necessary for the rapid administration of appropriate antimicrobials.

Objective: The aim of this study was to elucidate the current spectrum of pathogens and its variation by site of infection in sepsis.

Methods: This was a prospective nationwide cohort study of consecutive adult patients with sepsis in 59 intensive care units in Japan. The spectrum of pathogens was evaluated in all patients and in subgroups by site of infection. Regression analyses were conducted to evaluate the associations between the pathogens and mortality.

Results: The study cohort comprised 1184 patients. The most common pathogen was Escherichia coli (21.5%), followed by Klebsiella pneumoniae (9.0%). However, the pattern varied widely by site of infection; for example, gram-positive bacteria were the dominant pathogen in bone/soft tissue infection (55.7%) and cardiovascular infection (52.6%), but were rarely identified in urinary tract infection (6.4%). In contrast, gram-negative bacteria were the predominant pathogens in abdominal infection (38.4%) and urinary tract infection (72.0%). The highest mortality of 47.5% was observed in patients infected with methicillin-resistant Staphylococcus aureus, which was significantly associated with an increased risk of death (odds ratio 1.88, 95% confidence interval 1.22-2.91).

Conclusions: This study revealed the current spectrum of pathogens and its variation based on the site of infection, which is essential for empiric antimicrobial therapy against sepsis.
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http://dx.doi.org/10.1016/j.ijid.2020.11.168DOI Listing
February 2021

Characteristics and outcomes of frail patients with suspected infection in intensive care units: a descriptive analysis from a multicenter cohort study.

BMC Geriatr 2020 11 20;20(1):485. Epub 2020 Nov 20.

Division of Acute and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan.

Background: Frailty is associated with morbidity and mortality in patients admitted to intensive care units (ICUs). However, the characteristics of frail patients with suspected infection remain unclear. We aimed to investigate the characteristics and outcomes of frail patients with suspected infection in ICUs.

Methods: This is a secondary analysis of a multicenter cohort study, including 22 ICUs in Japan. Adult patients (aged ≥16 years) with newly suspected infection from December 2017 to May 2018 were included. We compared baseline patient characteristics and outcomes among three frailty groups based on the Clinical Frailty Scale (CFS) score: fit (score, 1-3), vulnerable (score, 4), and frail (score, 5-9). We conducted subgroup analysis of patients with sepsis defined as per Sepsis-3 criteria. We also produced Kaplan-Meier survival curves for 90-day survival.

Results: We enrolled 650 patients with suspected infection, including 599 (92.2%) patients with sepsis. Patients with a median CFS score of 3 (interquartile range [IQR] 3-5) were included: 337 (51.8%) were fit, 109 (16.8%) were vulnerable, and 204 (31.4%) were frail. The median patient age was 72 years (IQR 60-81). The Sequential Organ Failure Assessment scores for fit, vulnerable, and frail patients were 7 (IQR 4-10), 8 (IQR 5-11), and 7 (IQR 5-10), respectively (p = 0.59). The median body temperatures of fit, vulnerable, and frail patients were 37.5 °C (IQR 36.5 °C-38.5 °C), 37.5 °C (IQR 36.4 °C-38.6 °C), and 37.0 °C (IQR 36.3 °C-38.1 °C), respectively (p < 0.01). The median C-reactive protein levels of fit, vulnerable, and frail patients were 13.6 (IQR 4.6-24.5), 12.1 (IQR 3.9-24.9), 10.5 (IQR 3.0-21.0) mg/dL, respectively (p < 0.01). In-hospital mortality did not statistically differ among the patients according to frailty (p = 0.19). Kaplan-Meier survival curves showed little difference in the mortality rate during short-term follow-up. However, more vulnerable and frail patients died after 30-day than fit patients; this difference was not statistically significant (p = 0.25). Compared with the fit and vulnerable groups, the rate of home discharge was lower in the frail group.

Conclusion: Frail and vulnerable patients with suspected infection tend to have poor disease outcomes. However, they did not show a statistically significant increase in the 90-day mortality risk.
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http://dx.doi.org/10.1186/s12877-020-01893-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7677099PMC
November 2020

Comparison of prognostic models for burn patients: A retrospective nationwide registry study.

Burns 2020 12 17;46(8):1746-1755. Epub 2020 Oct 17.

Department of Emergency and Acute Medicine, Saitama Medical University International Medical Center, Saitama, Japan.

Background: Prognostic burn index (PBI) is a unique model utilized to predict mortality of burn patients in Japan. In contrast, other prediction models are rarely used in Japan, and their accuracy and predictive value are unknown. The present study aimed to compare commonly used burn prediction models and determine the appropriate model for mortality prediction in Japanese burn patients.

Methods: Japanese burn patients registered in the nationwide burn registry of Japanese Society for Burn Injury between April 1, 2011 and March 31, 2019 were reviewed retrospectively. The prognostic performance of PBI was compared with Baux score, revised Baux score, abbreviated burn severity index (ABSI), Ryan score and Belgian outcome in burn injury score (BOBI). The primary outcome was in-hospital mortality.

Results: The study included 7911 acute burn patients. The overall mortality rate was 10.7%, the median age was 52 (interquartile range, 26-72) years, and the median % total body surface area was 7% (interquartile range, 3%-17%). The areas under the receiver operating characteristic curve for PBI, Baux score, ABSI, revised Baux score, Ryan score, and BOBI were 0.940 (95% confidence interval [CI]: 0.931-0.948), 0.943 (95% CI: 0.934-0.951; p=0.002), 0.945 (95% CI: 0.937-0.953; p=0.058), 0.946 (95% CI: 0.937-0.953; p=0.002), 0.859 (95% CI: 0.846-0.870; p<0.001), and 0.896 (95% CI: 0.885-0.905; p<0.001), respectively.

Conclusion: Although the performance of PBI was good, it was not superior to the Baux score, revised Baux score, and ABSI. These three scores have a high prognostic accuracy. Hence, they are considered as alternative burn prognostic scores in Japan. The Baux score was an optimal prognostic model for patients with burns in Japan.
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http://dx.doi.org/10.1016/j.burns.2020.10.008DOI Listing
December 2020

Blood Interleukin-6 Levels Predict Multiple Organ Dysfunction in Critically Ill Patients.

Shock 2021 Jun;55(6):790-795

Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan.

Background: Predicting multiple organ dysfunction (MOD) in the late phase of critical illnesses is essential. Cytokines are considered biomarkers that can predict clinical outcomes; however, their predictive value for late-phase MOD is unknown. This study aimed to identify the biomarker with the highest predictive value for late-phase MOD.

Methods: This observational study prospectively evaluated data on adult patients with systemic inflammatory response syndrome, those who presented to the emergency department or were admitted to intensive care units in five tertiary hospitals (n = 174). Seven blood biomarkers levels (interleukin-6 [IL-6], IL-8, IL-10, tumor-necrosis factor-α, white blood cells, C-reactive protein, and procalcitonin) were measured at three timepoints (days 0, 1, and 2). The area under the receiver operating characteristic curve (AUC) was analyzed to evaluate predictive values for MOD (primary outcome, MOD on day 7 [late-phase]; secondary outcome, MOD on day 3 [early-phase]).

Results: Of the measured 7 biomarkers, blood IL-6 levels on day 2 had the highest predictive value for MOD on day 7 using single timepoint data (AUC 0.825, 95% confidence interval [CI] 0.754-0.879). Using three timepoint biomarkers, blood IL-6 levels had the highest predictive value of MOD on day 7 (AUC 0.838, 95% CI 0.768-0.890). Blood IL-6 levels using three timepoint biomarkers had also the highest predictive value for MOD on day 3 (AUC 0.836, 95% CI 0.766-0.888).

Conclusion: Of the measured biomarkers, blood IL-6 levels had the highest predictive value for MOD on days 3 and 7. Blood IL-6 levels predict early- and late-phase MOD in critically ill patients.
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http://dx.doi.org/10.1097/SHK.0000000000001678DOI Listing
June 2021

Hydrogen gas inhalation alleviates oxidative stress in patients with post-cardiac arrest syndrome.

J Clin Biochem Nutr 2020 Sep 3;67(2):214-221. Epub 2020 Apr 3.

Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo 160-8582, Japan.

Oxidative stress plays a key role in the pathophysiology of post-cardiac arrest syndrome. Molecular hydrogen reduces oxidative stress and exerts anti-inflammatory effects in an animal model of cardiac arrest. However, its effect on human post-cardiac arrest syndrome is unclear. We consecutively enrolled five comatose post-cardiac arrest patients (three males; mean age, 65 ± 15 years; four cardiogenic, one septic cardiac arrest) and evaluated temporal changes in oxidative stress markers and cytokines with inhaled hydrogen. All patients were treated with target temperature management. Hydrogen gas inhalation (2% hydrogen with titrated oxygen) was initiated upon admission for 18 h. Blood hydrogen concentrations, plasma and urine oxidative stress markers (derivatives of reactive oxygen metabolites, biological antioxidant potential, 8-hydroxy-2'-deoxyguanosine, -hexanoyl-lysine, lipid hydroperoxide), and cytokines (interleukin-6 and tumor necrosis factor-α) were measured before and 3, 9, 18, and 24 h after hydrogen gas inhalation. Arterial hydrogen concentration was measurable and it was equilibrated with inhaled hydrogen. Oxidative stress was reduced and cytokine levels were unchanged in cardiogenic patients, whereas oxidative stress was unchanged and cytokine levels were diminished in the septic patient. The effect of inhaled hydrogen on oxidative stress and cytokines in comatose post-cardiac arrest patients remains indefinite because of methodological weaknesses.
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http://dx.doi.org/10.3164/jcbn.19-101DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7533855PMC
September 2020

Resuscitative endovascular balloon occlusion of the aorta and traumatic out-of-hospital cardiac arrest: A nationwide study.

J Am Coll Emerg Physicians Open 2020 Aug 4;1(4):624-632. Epub 2020 Jul 4.

Department of Emergency and Critical Care Medicine Keio University School of Medicine Shinjuku Tokyo Japan.

Objective: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a less-invasive method for temporary hemostasis compared with cross-clamping the aorta through resuscitative thoracotomy (RT). Although the survival benefits of REBOA remained unclear, pathophysiological benefits were identified in patients with traumatic out-of-hospital cardiac arrest (t-OHCA). We examined the clinical outcomes of t-OHCA with the hypothesis that REBOA would be associated with higher survival to discharge compared with RT.

Methods: A retrospective cohort study was conducted using the Japan Trauma Data Bank (2004-2019). Adult patients with t-OHCA who had arrived without a palpable pulse and undergone aortic occlusion were included. Patients were divided into REBOA or RT groups, and propensity scores were developed using age, mechanism of injury, presence of signs of life, presence of severe head and/or chest injury, Injury Severity Score, and transportation time. Inverse probability weighting by propensity scores was performed to compare survival to discharge between the 2 groups.

Results: Among 13,247 patients with t-OHCA, 1483 were included in this study. A total of 144 (9.7%) patients were treated with REBOA, and 5 of 144 (3.5%) in the REBOA group and 10 of 1339 (0.7%) in the RT group survived to discharge. The use of REBOA was significantly associated with increased survival to discharge (odds ratio, 4.78; 95% confidence interval, 1.61-14.19), which was confirmed by inverse probability weighting (adjusted odds ratio, 3.73; 95% confidence interval, 1.90-7.32).

Conclusions: REBOA for t-OHCA was associated with higher survival to discharge. These results should be validated by further research.
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http://dx.doi.org/10.1002/emp2.12177DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7493555PMC
August 2020

Rapid collapse of the inferior vena cava in a patient with cardiac arrest induced by anaphylactic shock after iodinated contrast medium injection.

J Am Coll Emerg Physicians Open 2020 Aug 25;1(4):379-382. Epub 2020 Jun 25.

Department of Emergency and Critical Care Medicine Keio University School of Medicine Tokyo Japan.

Anaphylactic shock to contrast media can progress to cardiac arrest despite appropriate treatment. During anaphylactic shock to contrast media, rapid vasodilation and a massive fluid shift can occur. Here we report a patient who developed cardiac arrest induced by anaphylactic shock to iodinated contrast medium and exhibited rapid collapse of the inferior vena cava (IVC) on enhanced abdominal computed tomography (CT) images. The patient underwent postsurgical unenhanced and contrast-enhanced abdominal CT follow-up of cecum cancer. She had neither allergy nor medical history except for the cancer. She did not complain of any symptoms immediately after completion of the CT. However, she developed anaphylactic shock and pulseless electrical activity cardiac arrest only 2 minutes after finishing the CT despite appropriate treatment. Emergency physicians successfully treated the patient using advanced life support and targeted temperature management. She recovered with good overall and cerebral performance (Overall Performance Category (OPC) 1 and Cerebral Performance Category (CPC) 1). On the contrast-enhanced CT images, she exhibited rapid collapse of the IVC, although it was normal on the unenhanced CT images. The collapsed IVC is a good indicator of hypovolemia in patients with trauma. In this case, we considered that rapid vasodilation and a massive volume shift might have caused the collapsed IVC. This finding suggests the importance of aggressive volume resuscitation as well as epinephrine injection in patients with anaphylactic shock to contrast media. Furthermore, this finding occurred before the onset of clinical symptoms, and there is a possibility that it could be used as an indicator of anaphylactic shock to contrast media.
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http://dx.doi.org/10.1002/emp2.12166DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7493500PMC
August 2020