Diphenyl-tetrazol-propanamide Derivatives Act as Dual-Specific Antagonists of Platelet CLEC-2 and Glycoprotein VI.

BACKGROUND: Platelet C-type lectin-like receptor 2 (CLEC-2) induces platelet activation and aggregation after clustering by its ligand podoplanin (PDPN). PDPN, which is not normally expressed in cells in contact with blood flow, is induced in inflammatory immune cells and some malignant tumor cells, thereby increasing the risk of venous thromboembolism (VTE) and tumor metastasis. Therefore, small-molecule compounds that can interfere with the PDPN-CLEC-2 axis have the potential to become selective antiplatelet agents. METHODS AND RESULTS: Using molecular docking analysis of CLEC-2 and a PDPN-CLEC-2 binding-inhibition assay, we identified a group of diphenyl-tetrazol-propanamide derivatives as novel CLEC-2 inhibitors. A total of 12 hit compounds also inhibited PDPN-induced platelet aggregation in humans and mice. Unexpectedly, these compounds also fit the collagen-binding pocket of the glycoprotein VI molecule, thereby inhibiting collagen interaction. These compounds also inhibited collagen-induced platelet aggregation, and one compound ameliorated collagen-induced thrombocytopenia in mice. For clinical use, these compounds will require a degree of chemical modification to decrease albumin binding. CONCLUSION: Nonetheless, as dual activation of platelets by collagen and PDPN-positive cells is expected to occur after the rupture of atherosclerotic plaques, these dual antagonists could represent a promising pharmacophore, particularly for arterial thrombosis, in addition to VTE and metastasis.

Is resuscitative endovascular balloon occlusion of the aorta for computed tomography diagnosis feasible or not? A Japanese single-center, retrospective, observational study.

BACKGROUND: Advances in medical equipment have resulted in changes in the management of severe trauma. The role of resuscitative endovascular balloon occlusion of the aorta (REBOA) in this scenario is still unclear. This study aimed to evaluate the usage of REBOA and utility of computed tomography (CT) in the setting of aortic occlusion in our current trauma management. METHODS: This Japanese single-tertiary center, retrospective, and observational study analyzed 77 patients who experienced severe trauma and persistent hypotension between October 2014 and March 2020. RESULTS: All patients required urgent hemostasis. Twenty patients underwent REBOA, 11 underwent open aortic cross-clamping, and 46 did not undergo aortic occlusion. Among patients who underwent aortic occlusion, 19 patients underwent prehemostasis CT, and 7 patients underwent operative exploration without prehemostasis CT for identifying active bleeding sites. The 24-hour and 28-day survival rates in patients who underwent CT were not inferior to those in patients who did not undergo CT (24-hour survival rate, 84.2% vs. 57.1%; 28-day survival rate, 47.4% vs. 28.6%). Moreover, the patients who underwent CT had less discordance between primary hemostasis site and main bleeding site compared with patients who did not undergo CT (5% vs. 71.4%, p = 0.001). In the patients who underwent prehemostasis CT, REBOA was the most common approach of aortic occlusion. Most of the bleeding control sites were located in the retroperitoneal space. There were many patients who underwent interventional radiology for hemostasis. CONCLUSION: In a limited number of patients whose cardiac arrests were imminent and in whom no active bleeding sites could be clearly identified without CT findings, REBOA for CT diagnosis may be effective; however, further investigations are needed. LEVEL OF EVIDENCE: Therapeutic/care management study, level V.

Indications for early plasma transfusion and its optimal use following trauma.

AIM: This study aimed to evaluate the effect of plasma transfusion before urgent hemostasis initiation on in-hospital mortality in hemodynamically unstable patients with severe trauma. METHODS: This retrospective observational study of patients admitted to hospital between January 2011 and January 2019 grouped patients according to whether plasma transfusion was initiated before (Before group) or after (After group) hemostasis initiation. Patients with severe trauma who were unable to wait for plasma transfusion and had started hemostasis before the plasma infusion were excluded. We used multivariable logistic regression analysis to determine the effect of plasma transfusion before the initiation of urgent hemostasis on in-hospital mortality. RESULTS: We included 47 and 73 patients in the Before and After groups, respectively. Blunt trauma was more common, and the D-dimer levels and Injury Severity Score were significantly higher in the Before group than in the After group (median D-dimer, 57.5 versus 38.1 µg/mL; P = 0.040; median Injury Severity Score, 50 versus 34; P < 0.001). Plasma given before hemostasis initiation was associated with significantly lower in-hospital mortality (adjusted odds ratio, 0.27; 95% confidence interval, 0.078-0.900; P = 0.033) in contrast with the total plasma volume given in the first 6 or 24 h. CONCLUSION: Plasma transfusion before hemostasis initiation could be an important factor for improving outcomes in hemodynamically unstable patients with blunt trauma, high D-dimer levels, or a high Injury Severity Score.

Impact of a streamlined trauma management approach and determinants of mortality among hemodynamically unstable patients with severe multiple injuries: a before-and-after retrospective cohort study.

BACKGROUND: Trauma management requires a multidisciplinary approach, but coordination of staff and procedures is challenging in patients with severe trauma. In October 2014, we implemented a streamlined trauma management system involving emergency physicians trained in severe trauma management, surgical techniques, and interventional radiology. We evaluated the impact of streamlined trauma management on patient management and outcomes (study 1) and evaluated determinants of mortality in patients with severe trauma (study 2). METHODS: We conducted a retrospective cohort study of 125 patients admitted between January 2011 and 2019 with severe trauma (Injury Severity Score ≥16) and persistent hypotension (≥2 systolic blood pressure measurements <90 mm Hg). Patients were divided into a Before cohort (January 2011 to September 2014) and an After cohort (October 2014 to January 2019) according to whether they were admitted before or after the new approach was implemented. The primary outcome was in-hospital mortality. RESULTS: Compared with the Before cohort (n=59), the After cohort (n=66) had a significantly lower in-hospital mortality (36.4% vs. 64.4%); required less time from hospital arrival to initiation of surgery/interventional radiology (median, 41.0 vs. 71.5 minutes); and was more likely to undergo resuscitative endovascular balloon occlusion of the aorta (24.2% vs. 6.8%). Plasma administration before initiating hemostasis (adjusted OR 1.49 (95% CI 1.04 to 2.14)), resuscitative endovascular balloon occlusion of the aorta (9.48 (95% CI 1.25 to 71.96)), and shorter time to initiation of surgery/interventional radiology (0.97 (95% CI 0.96 to 0.99)) were associated with significantly lower mortality. DISCUSSION: Implementing a streamlined trauma management protocol improved outcomes among hemodynamically unstable patients with severe multiple trauma. LEVEL OF EVIDENCE: Level III.

Serum potassium level as a biomarker for acute caffeine poisoning.

AIM: Acute caffeine poisoning presents with hypokalemia, although a relationship between potassium levels and blood concentrations of caffeine has not been established. A correlation between serum potassium level and blood caffeine concentration could establish serum potassium as a simple marker to assess caffeine toxicity in patients with acute toxicity. We investigated whether serum potassium, a symptom of acute caffeine poisoning, could be a parameter correlated with blood caffeine levels. METHODS: We enrolled 85 patients treated for acute caffeine poisoning between January 2012 and March 2019 with blood caffeine levels measured after an overdose of a caffeine-containing over-the-counter drug and for whom serum potassium levels were available. We examined the correlation between serum potassium and blood caffeine concentration. A receiver operating characteristic curve was created with serum potassium values to stratify participants into two groups by blood caffeine concentrations: <20 or ≥20 mg/L (toxic dose) and <80 or ≥80 mg/L (lethal dose). The lethal cut-off value was calculated. RESULTS: The correlation coefficient between serum potassium level and blood caffeine concentration was -0.612 (R 2 = 0.374), indicating a negative correlation. The areas under the curve at blood caffeine concentrations of 20 mg/L (toxic dose) and 80 mg/L (lethal dose) and serum potassium levels were 0.716 and 0.888 (sensitivity, 0.829 and 0.919; specificity, 0.568 and 0.818; cut-off, 3.3 mEq/L and 2.9 mEq/L), respectively. CONCLUSION: Serum potassium levels are associated with blood caffeine concentrations; K+ of 3.3 mEq/L and 2.9 mEq/L indicate acute caffeine poisoning in the toxic and lethal dose, respectively.

Podoplanin is indispensable for cell motility and platelet-induced epithelial-to-mesenchymal transition-related gene expression in esophagus squamous carcinoma TE11A cells.

BACKGROUND: The transmembrane glycoprotein podoplanin (PDPN) is upregulated in some tumors and has gained attention as a malignant tumor biomarker. PDPN molecules have platelet aggregation-stimulating domains and, are therefore, suggested to play a role in tumor-induced platelet activation, which in turn triggers epithelial-to-mesenchymal transition (EMT) and enhances the invasive and metastatic activities of tumor cells. In addition, as forced PDPN expression itself can alter the propensity of certain tumor cells in favor of EMT and enhance their invasive ability, it is also considered to be involved in the cell signaling system. Nevertheless, underlying mechanisms of PDPN in tumor cell invasive ability as well as EMT induction, especially by platelets, are still not fully understood. METHODS: Subclonal TE11A cells were isolated from the human esophageal squamous carcinoma cell line TE11 and the effects of anti-PDPN neutralizing antibody as well as PDPN gene knockout on platelet-induced EMT-related gene expression were measured. Also, the effects of PDPN deficiency on cellular invasive ability and motility were assessed. RESULTS: PDPN-null cells were able to provoke platelet aggregation, suggesting that PDPN contribution to platelet activation in these cells is marginal. Nevertheless, expression of platelet-induced EMT-related genes, including vimentin, was impaired by PDPN-neutralizing antibody as well as PDPN deficiency, while their effects on TGF-ß-induced gene expression were marginal. Unexpectedly, PDPN gene ablation, at least in either allele, engendered spontaneous N-cadherin upregulation and claudin-1 downregulation. Despite these seemingly EMT-like alterations, PDPN deficiency impaired cellular motility and invasive ability even after TGF-ß-induced EMT induction. CONCLUSIONS: These results suggested that, while PDPN seems to function in favor of maintaining the epithelial state of this cell line, it is indispensable for platelet-mediated induction of particular mesenchymal marker genes as well as the potentiation of motility and invasion capacity.

Usefulness of next-generation DNA sequencing for the diagnosis of urinary tract infection.

Acute urinary tract infection (UTI) is a highly common clinical condition. Although bacterial culture is the gold standard diagnostic test, false negative results may be possible, leading to the pathogen being unidentified. In recent years, bacterial DNA sequencing analysis has garnered much attention, but clinical studies are rare in Japan. In this study, we assessed the usefulness of next-generation DNA sequencing (NGS) analysis for acute UTI patients. We thus performed an observational, retrospective case series study. Urine and blood samples were collected from ten acute UTI patients, of whom four had also been diagnosed with urosepsis. Seven variable regions of bacterial 16S rRNA genes were amplified by PCR and then sequenced by IonPGM. The identified bacterial species were compared with those identified using the culture tests and the clinical parameters were analyzed. As a result, the NGS method effectively identified predominant culture-positive bacteria in urine samples. The urine NGS also detected several culture-negative species, which have been reported to be potentially pathogenic. Out of four urosepsis cases, three were pathogen-positive in blood NGS results, while two were pathogen-negative in blood culture. In one sepsis case, although blood culture was negative for Escherichia coli, this species was detected by blood NGS. For non-sepsis cases, however, blood NGS, as well as blood culture, was less effective in detecting bacterial signals. In conclusion, NGS is potentially useful for identifying pathogenic bacteria in urine from acute UTI patients but is less applicable in patients who do not meet clinical criteria for sepsis.

A pull-down and slot blot-based screening system for inhibitor compounds of the podoplanin-CLEC-2 interaction.

Podoplanin, a transmembrane glycoprotein, is overexpressed in certain types of tumors and induces platelet aggregation by binding to C-type lectin-like receptor 2 (CLEC-2) on the platelet membrane. Activated platelets release granule components, which in turn, trigger epithelial-mesenchymal transition and confer invasive capacity to the tumor cells. Therefore, blocking the podoplanin-CLEC-2 interaction by a small-molecule compound is a potential therapeutic strategy to prevent cancer metastasis and invasion. To effectively identify such inhibitory compounds, we have developed a pull-down-based inhibitory compound screening system. An immunoglobulin Fc domain-CLEC-2 fusion protein was used as a bait to capture podoplanin derived from podoplanin-overexpressing HeLa cells in the presence and absence of the test compound. The protein complex was then pulled down using protein A beads. To shorten the turnaround time, increase throughput, and decrease the workload for the operators, centrifugal filter units were employed to separate free and bound podoplanin, instead of using customary aspiration-centrifugation washing cycles. Slot blotting was also utilized in lieu of gel electrophoresis and electrical transfer. Thus, the use of our pull down screening system could facilitate the effective selection of potential inhibitor compounds of the podoplanin-CLEC-2 interaction for cancer therapy. Importantly, our methodology is also applicable to targeting other protein-protein interactions.

Assessment of Concentrations of Four Phenothiazine Antipsychotics in Serum and Whole Blood Using Different Diatomaceous Earth-based Solid-phase Columns: A Comparative Analysis.

This study attempted to determine the phenothiazine antipsychotics concentration in serum and whole blood samples using various diatomaceous earth-based solid-phase columns and elution solvents and subsequently evaluate their efficiency. Phenothiazine antipsychotics concentrations of 5 - 2000 ng/mL were extracted from serum and whole blood using each column. All compounds were analyzed using liquid chromatography-tandem mass spectrometry. Phenothiazine antipsychotics extraction in serum and whole blood using diatomaceous earth-based solid-phase columns seemed to have an affinity with the elution solvent.

Current strategy for hollow viscus injury with active bleeding: A case report.

Despite rapid advancements in medical technologies, the use of interventional radiology in a patient with hemodynamic instability or hollow viscus injury remains controversial. Here, we discuss important aspects regarding the use of interventional radiology for such patients. A 74-year-old Japanese male climber was injured following a 10 m fall. On admission, his systolic blood pressure was 40 mmHg. He had disturbance of consciousness and mild upper abdominal pain without peritoneal irritation. Focused assessment sonography for trauma indicated massive hemorrhage in the intra-abdominal cavity. Plain radiographs revealed hemopneumothorax with right-side rib fractures. Thoracostomy to the right thoracic cavity and massive transfusion were immediately performed. Consequently, a sheath catheter was inserted into the common femoral artery for interventional radiology. His systolic blood pressure increased to 80 mmHg owing to rapid transfusion. In the computed tomography scan room, based on computed tomography findings, we judged that it was possible to achieve hemostasis by interventional radiology. The time from hospital admission to entering the angiography suite was 38 min. Transcatheter arterial embolization for hemorrhage control was performed without complications. Following transcatheter arterial embolization, he was admitted to the intensive care unit. All injuries could be treated conservatively without surgery. His post-interventional course was uneventful, and he recovered completely after rehabilitation. Hemorrhage control using interventional radiology should be assessed as a first-line treatment, even in hemodynamically unstable patients having a hollow viscus injury with active bleeding, without obvious findings that indicate surgical repair.

Psychiatric Hospitalization after Emergency Treatment for Deliberate Self-Harm is Associated with Repeated Deliberate Self-Harm.

The objective of this study was to evaluate whether treatment at a psychiatric hospital reduces the risk of repeating parasuicide. Participants were 4,483 parasuicide patients admitted to an emergency department between July 2003 and March 2012. We analyzed the effectiveness of psychiatric hospitalization in preventing repeated parasuicide. We adjusted for background factors using multivariate logistic regression. Effects of psychiatric hospitalization upon the likelihood of repeated parasuicide within 1 year varied by age (especially those aged <35 years), indicating that hospitalization was a significant risk factor. We must be mindful of the risk of repeated parasuicide following discharge in young patients and to provide them with ongoing outpatient care and multimodal support.

Effect of resuscitative endovascular balloon occlusion of the aorta in hemodynamically unstable patients with multiple severe torso trauma: a retrospective study.

Background: Although resuscitative endovascular balloon occlusion of the aorta (REBOA) may be effective in trauma management, its effect in patients with severe multiple torso trauma remains unclear. Methods: We performed a retrospective study to evaluate trauma management with REBOA in hemodynamically unstable patients with severe multiple trauma. Of 5899 severe trauma patients admitted to our hospital between January 2011 and January 2018, we selected 107 patients with severe torso trauma (Injury Severity Score > 16) who displayed persistent hypotension [≥ 2 systolic blood pressure (SBP) values ≤ 90 mmHg] regardless of primary resuscitation. Patients were divided into two groups: trauma management with REBOA (n = 15) and without REBOA (n = 92). The primary endpoint was the effectiveness of trauma management with REBOA with respect to in-hospital mortality. Secondary endpoints included time from arrival to the start of hemostasis. Multivariable logistic regression analysis, adjusted for clinically important variables, was performed to evaluate clinical outcomes. Results: Trauma management with REBOA was significantly associated with decreased mortality (adjusted odds ratio of survival, 7.430; 95% confidence interval, 1.081-51.062; p = 0.041). The median time (interquartile range) from admission to initiation of hemostasis was not significantly different between the two groups [with REBOA 53.0 (40.0-80.3) min vs. without REBOA 57.0 (35.0-100.0) min ]. The time from arrival to the start of balloon occlusion was 55.7 ± 34.2 min. SBP before insertion of REBOA was 48.2 ± 10.5 mmHg. Total balloon occlusion time was 32.5 ± 18.2 min. Conclusions: The use of REBOA without a delay in initiating resuscitative hemostasis may improve the outcomes in patients with multiple severe torso trauma. However, optimal use may be essential for success.

Multiple Patients With Heatstroke Air Evacuated by Agreement Concerning Collaboration.

On August 30, 2017, the wet-bulb globe temperature was 30°C. Three female military personnel fell unconscious almost simultaneously around noon after a long-distance march that had started at 6 am. The fire department in Gotenba received a 119 call [at 1:16 PM] and requested dispatch of the eastern Shizuoka doctor helicopter (DH) because it would take about 1 hour from the scene to arrive at our hospital by ground ambulance. At that time, the DH of eastern Shizuoka was transporting an injured patient to Kanagawa Prefecture, so the flight dispatcher of the DH of eastern Shizuoka decided to request support DHs from Kanagawa Prefectures based on an agreement concerning collaboration using the DH. The DH of Kanagawa Prefecture met 1 of the patients and transported her to its base hospital. The remaining 2 patients were then transported by the DH of eastern Shizuoka to its base hospital after completing the previous mission. All patients obtained a survival discharge without major complications after receiving proper treatment and rehabilitation. The agreement concerning collaboration using multiple DHs was important in this case, and dispersion transportation was successfully achieved.

Impact of emergency physicians competent in severe trauma management, surgical techniques, and interventional radiology on trauma management.

AIM: Despite recent advancements in trauma management following introduction of interventional radiology (IVR) and damage-control strategies, challenges remain regarding optimal use of resources for severe trauma. METHODS: In October 2014, we implemented a trauma management system comprising emergency physicians competent in severe trauma management, surgical techniques, and IVR. To evaluate this system, of 5,899 trauma patients admitted to our hospital from January 2011 to January 2018, we selected 107 patients with severe trauma (injury severity score ≥ 16) who presented with persistent hypotension (two or more systolic blood pressure measurements <90 mmHg), regardless of primary resuscitation. Patients were divided according to the date of admission: Conventional (January 2011-September 2014) or Current (October 2014-January 2018). The primary end-point was in-hospital mortality. Secondary end-points included time from arrival to start of surgery/IVR. RESULTS: There were 59 patients in the Conventional group and 48 in the Current group. Although patients in the Current group were more severely ill compared with those in the Conventional group, mortality in the Current group was significantly lower (Conventional 64.4% versus Current 41.7%, P = 0.019), especially among patients whose first intervention was IVR (Conventional 75.0% versus Current 28.6%, P = 0.001). Time from arrival to initiation of surgery/IVR was shorter in the Current group (Conventional 71.5 [53.8-130.8] min versus Current 41.0 [26.0-58.5] min, P < 0.0001). CONCLUSIONS: This trauma management system based on emergency physicians competent not only in severe trauma management, but also surgical techniques and IVR, could improve outcomes in patients with severe multiple lethal trauma.

Cardiac arrest caused by diphenhydramine overdose.

CASE: A 45-year-old man presented to our emergency department with disturbance of consciousness; he had mentioned to his family earlier about a drug overdose. When first responders arrived, he suffered cardiac arrest. Cardiac arrest due to drug overdose was diagnosed.The patient was supported with venoarterial extracorporeal membrane oxygenation. Arterial blood gas showed mixed acidosis, and electrocardiogram showed junctional rhythm and complete right bundle branch block. OUTCOME: The patient's blood pressure gradually decreased, and he died on the third day of hospitalization. After death, his serum diphenhydramine concentration at the time of arrival was found to be 18.7 µg/mL. CONCLUSION: Although diphenhydramine is regarded as a safe medication, it shows dose-dependent toxicity. High intake is associated with death; therefore, caution should be exercised in cases of drug overdose. Developing a procedure for rapid measurement in the emergency department should be a priority.

A Case of Acute Respiratory Distress Syndrome Caused by Waterproofing Spray Inhalation.

We report the case of a 62-year-old man who used approximately one can of waterproofing spray in an enclosed room and, then, smoked a cigarette. He developed a fever of 39°C with respiratory distress and was transported by ambulance to his usual doctor. Since his respiratory state was very severe, he was transferred to our hospital. The patient had a smoking habit of 20 cigarettes per day for approximately 42 years. Chest computed tomography (CT) on arrival showed ground glass opacity (GGO) in the bilateral lungs with emphysematous change. We diagnosed the patient with acute respiratory distress syndrome (ARDS) because of severe hypoxemia. Based on the symptoms' progress, the cause of ARDS was thought to be lung injury due to waterproofing spray inhalation, and treatment was accordingly initiated. Several reports have described lung injury caused by waterproofing spray inhalation; however, severe cases that progress to ARDS are rare. We believe that the aggravation was caused by smoking after inhaling the waterproofing spray and pre-existing pulmonary lesions, such as emphysema. Education regarding the precautions to be taken when using waterproofing spray is necessary.

The prehospital quick SOFA score is associated with in-hospital mortality in noninfected patients: A retrospective, cross-sectional study.

This study aimed to determine the accuracy of the quick Sequential Organ Failure Assessment (qSOFA) score in predicting mortality among prehospital patients with and without infection. This single-center, retrospective, cross-sectional study was conducted among patients who arrived via the emergency medical services (EMS). We calculated the qSOFA score and Modified Early Warning Score (MEWS) from prehospital records. We identified patients as infected if they received intravenous antibiotics at the emergency department or within the first 24 hours. Receiver operating characteristic analysis was used to evaluate and compare the performance of the qSOFA score, each physiological parameter, and the MEWS in predicting admission and in-hospital mortality in patients with and without infection. Multivariate analysis was used to evaluate the qSOFA score and other risk factors. Out of 1574 prehospital patients, 47.1% were admitted and 3.2% died in the hospital. The performance of the qSOFA score in predicting in-hospital mortality in noninfected patients was 0.70, higher than for each parameter and the MEWS. The areas under the curve for the qSOFA+ model vs. the qSOFA- model was 0.77 vs. 0.68 for noninfected patients (p <0.05) and 0.71 vs. 0.68 for infected patients (p = 0.41). The likelihood ratio test comparing the qSOFA- and qSOFA+ groups demonstrated significant improvement for noninfected patients (p <0.01). Multivariate regression analysis for in-hospital mortality demonstrated that the qSOFA score is an independent prognosticator for in-hospital mortality, especially among noninfected patients (odds ratio, 3.60; p <0.01). In conclusion, the prehospital qSOFA score was associated with in-hospital mortality in noninfected patients and may be a beneficial tool for identifying deteriorating patients in the prehospital setting.

Detection of pathogenic bacteria in the blood from sepsis patients using 16S rRNA gene amplicon sequencing analysis.

Prompt identification of causative pathogenic bacteria is imperative for the treatment of patients suffering from infectious diseases, including sepsis and pneumonia. However, current culture-based methodologies have several drawbacks including their limitation of use to culturable bacterial species. To circumvent these problems, we attempted to detect bacterial DNA in blood using next-generation DNA sequencing (NGS) technology. We conducted metagenomic and 16S ribosomal RNA (rRNA) gene amplicon sequencing of DNA extracted from bacteria-spiked blood using an Ion Personal Genome Machine. NGS data was analyzed using our in-house pipeline Genome Search Toolkit and database GenomeSync. The metagenomic sequencing analysis successfully detected three gram-positive and three gram-negative bacteria spiked in the blood, which was associated with a significant portion of non-bacterial reads, even though human blood cells were separated by low-speed centrifugation prior to DNA extraction. Sequencing analysis of seven variable regions of the 16S rRNA gene amplicon also successfully detected all six bacteria spiked in the blood. The methodology using 16S rRNA gene amplicon analysis was verified using DNA from the blood of six patients with sepsis and four healthy volunteers with potential pathogenic bacteria in the blood being identified at the species level. These findings suggest that our system will be a potential platform for practical diagnosis in the future.

Optimal Treatment for Ruptured Pancreaticoduodenal Artery Aneurysm Caused by Celiac Artery Obstruction Due to Celiac Artery Dissection.

A pancreaticoduodenal artery (PDA) aneurysm develops due to increased flow through the pancreaticoduodenal arcade in the setting of celiac or superior mesenteric artery occlusion. Additionally, there is no evidence on the computed tomography scan or angiography images that the dissection process extends to the PDA arcade. Moreover, the optimal treatment protocols for PDA aneurysms with celiac artery obstruction and for celiac artery dissection are controversial. We report 2 cases of ruptured PDA aneurysms caused by celiac artery obstruction due to celiac artery dissection in which the aneurysm was excluded, but celiac artery revascularization was not performed successfully. Our cases indicate that endovascular management for ruptured PDA aneurysms and conservative management for celiac artery obstruction due to celiac artery dissection are feasible as first-line treatment in such cases.