Impact of physician-staffed ground emergency medical services-administered pre-hospital trauma care on in-hospital survival outcomes in Japan.

PURPOSE: In Japan, the vehicle used in pre-hospital trauma care systems with physician-staffed ground emergency medical services (GEMS) is referred to as a "doctor car". Doctor cars are highly mobile physician-staffed GEMS that can provide complex pre-hospital trauma management using various treatment strategies. The number of doctor car operations for patients with severe trauma has increased. Considering facility factors, the association between doctor cars and patient outcomes remains unclear. Therefore, this study aimed to examine the relationship between doctor cars for patients with severe trauma and survival outcomes in Japan. METHODS: A nationwide retrospective cohort study was conducted to compare the impact of the doctor car group with the non-physician-staffed GEMS group on in-hospital survival in adult patients with severe trauma. The data were analyzed using multivariable logistic regression models with generalized estimating equations. RESULTS: This study included 372,365 patients registered in the Japan Trauma Data Bank between April 2009 and March 2019. Of the 49,144 eligible patients, 2361 and 46,783 were classified into the doctor car and non-physician staffed GEMS groups, respectively. The adjusted odds ratio (OR) for survival was significantly higher in the doctor car group than in the non-physician staffed GEMS group (adjusted OR = 1.228 [95% confidence interval 1.065-1.415]). CONCLUSION: Using nationwide data, this novel study suggests that doctor cars improve the in-hospital survival rate of patients with severe trauma in Japan. Therefore, doctor cars could be an option for trauma strategies.

Scalable Synthesis of Porous Silicon by Acid Etching of Atomized Al-Si Alloy Powder for Lithium-Ion Batteries.

Si anodes have attracted considerable attention for their potential application in next-generation lithium-ion batteries because of their high specific capacity (Li15Si4, 3579 mAh g-1) and elemental abundance. However, Si anodes have not yet been practically applied in lithium-ion batteries because the volume change associated with lithiation and delithiation degrades their capacity during cycling. Instead of considering the active material, we focused on the structural design and developed a scalable process for producing Si anodes with excellent cycle characteristics while precisely controlling the morphology. Al-Si alloy powders were prepared by gas atomization, and porous Si with a skeletal structure was prepared by leaching Al using HCl. Porous Si (p-Si12, p-Si19) prepared from Al88Si12 and Al81Si19 comprised resinous eutectic Si, and porous Si (p-Si25) prepared from Al75Si25 comprised lumpy primary Si and resinous eutectic Si. The porosity of the Si anodes varied from 63% to 76%, depending on the Si composition. The p-Si19 anode displayed the finest pore distribution (20-200 nm), excellent rate characteristics, a reversible discharge capacity of 1607 mAh g-1 after 200 cycles at a rate of 0.1 C with a Coulombic efficiency of over 97%, and high stability. The performances of the p-Si25 and p-Si19 electrodes began to decrease after 250 and 850 cycles, respectively, with a constant-charge capacity of 1000 mAh g-1 and at a rate of 0.2 C. In contrast, the p-Si12 anode maintained its discharge capacity at 1000 mAh g-1 for up to 1000 cycles without degradation. Therefore, the developed manufacturing process is expected to produce porous Si as an active material in lithium-ion batteries for high capacity and long life at an industrial scale.

A Patient with Werner's Syndrome Who Underwent Aortic Valve Replacement through Minimally Invasive Cardiac Surgery.

Werner's syndrome (WS) is a genetic disorder presenting with premature senility. In the present study, we performed minimally invasive cardiac surgery (MICS)-aortic valve replacement (AVR) on a patient with Werner's syndrome who presented with aortic stenosis. The patient, a 49-year-old Japanese man, was brought to the emergency room with dyspnea during exercise. On echocardiography, severe aortic stenosis was found and surgery was planned. He had poorly controlled diabetes mellitus and underwent MICS-AVR to avoid the risk of sternal osteomyelitis, which resulted in a good outcome. The aortic valve had sclerotic changes and a genetic disease was suspected based on the onset of aortic stenosis at a young age, characteristic appearance, and various signs of aging. Genetic testing led to the diagnosis of WS.

Interfacial Distribution of Nafion Ionomer Thin Films on Nitrogen-Modified Carbon Surfaces.

Chemically modified carbon supports for the cathode catalyst layers of polymer electrolyte fuel cells (PEFCs) show considerable promise for boosting the oxygen reduction reaction. This study evaluated the ionomer distribution of Nafion ionomer thin films on nitrogen (N)-modified carbon surfaces along their depth direction. Neutron reflectivity (NR) measurements performed using the double-contrast technique with H2O and D2O revealed that the introduction of N functional groups to carbon thin films promoted ionomer adsorption onto the surface under wet conditions (22 °C, 85% relative humidity). Molecular dynamics (MD) simulations conducted to verify the origin of the robust contact between the ionomer and N-modified carbon surface revealed an ionomer adsorption mechanism on the N-modified carbon surfaces, which involved Coulomb interactions between the positively charged carbon surface and the ionomer side chains with negatively charged sulfonic acid groups. The positive surface charge, which was determined using the contents of the N functional groups estimated by X-ray photoelectron spectroscopy, was found to be sufficient as an impetus for ionomer adsorption. This strategy involving NR measurements and MD simulations can provide insights into the solid-ionomer interfacial structures in a cathode catalyst layer and can therefore be extensively employed in studies on PEFCs.

Effects of Lithium Bis(oxalate)borate Electrolyte Additive on the Formation of a Solid Electrolyte Interphase on Amorphous Carbon Electrodes by Operando Time-Slicing Neutron Reflectometry.

Comprehensive analyses were performed using neutron reflectivity and hard X-ray photoelectron spectroscopy to understand the structure and composition of the solid electrolyte interphase (SEI) layer during charge-discharge processes and because of the addition of lithium bis(oxalate)borate (LiBOB) to improve the battery performance. The chemical composition of the SEI was assessed using these methods, and the amount of Li+ intercalated in the anode during the electrochemical reaction was evaluated. The results demonstrated that Li2C2O4 was produced initially but later decomposed to Li2CO3 on the first charge cycle. Presumably, the SEI layer formed by the decomposition of LiBOB was a single dense layer and chemically stable during the further charge-discharge processes owing to the difference in the reaction process. Therefore, the reduced Li+ transfer resistance and charging capacity accounted for the substantial improvement contributed by adding LiBOB. Moreover, the charges used for the intercalation of Li+ and SEI formation during the two-cycle processes were analyzed. The addition of LiBOB increased the discharge capacity of the anode and provided an additional charge used for SEI formation, presumably for decomposing Li2C2O4, which could reflect the durability of the Li-ion batteries. The electrode, electrolyte, and charge-discharge reactions affect the SEI properties and consequently the electrochemical reactions. Therefore, additional investigations under different charge-discharge conditions would reveal important characteristics such as the charge and discharge efficiency, output performance, and safety.

A patient with Marfan's syndrome who developed an acute aortic dissection at 28 weeks of pregnancy treated with aortic root replacement.

The patient was a 31-year-old pregnant woman who gave birth to her first child by vaginal delivery 7 years ago. She was diagnosed with Marfan's syndrome based on physical findings; however, the condition was not diagnosed before the onset. The patient developed acute aortic dissection at 28 weeks of pregnancy. A cesarean section was first performed to save the patient's life; then, a total hysterectomy was performed to prevent the risk of postpartum hemorrhage. Furthermore, aortic root replacement was performed using a temporary mechanical valve. The patient and her child have survived without any complications.

Thickness of carbon coatings on silicon materials determined by hard X-ray photoelectron spectroscopy at multiple photon energies.

Hard X-ray photoelectron spectroscopy at multiple photon energies is used to investigate the surface structure of carbon coatings on silicon materials destined for use as negative electrodes in lithium-ion batteries. The photoelectron intensity from the carbon coatings decreases with an increase in the kinetic energy of the photoelectron. By fitting the photoelectron intensity versus energy to numerically derived curves, the thickness and coverage of the carbon coatings can be obtained. The results are in agreement with the values suggested by the cross-sectional secondary-electron microscopy images of the carbon coatings, although the thickness should be corrected by accounting for the rectangular parallelepiped structure of the silicon material.

The Effect of Steroid Therapy on Postoperative Inflammatory Response after Endovascular Abdominal Aortic Aneurysm Repair.

Objectives: Unexpected systemic inflammatory response with high fever and increase in C-reactive protein (CRP) occurred frequently after endovascular abdominal aortic aneurysm repair (EVAR). This excessive inflammatory response affects the postoperative course. We evaluated the effects of steroid on the postoperative inflammatory response after EVAR. Methods: Steroid therapy, intravenous infusion of methylprednisolone 1000 mg just after the anesthesia induction, was started since December 2012. After induction of the steroid therapy, 25 patients underwent EVAR with steroid therapy (Group S). These patients were compared with the 65 patients who underwent EVAR without steroid therapy (Group C) in white blood cell count (WBC), CRP and maximum body temperature (BT) on postoperative day 1-5. Results: There was no significant difference in age, female gender, operation time, maximum aneurysm diameter between the two groups. There was no postoperative infective complication in the both groups. WBC did not differ between the two groups; however, CRP was significantly suppressed in Group S than in Group C on POD 1, 3 and 5. Also BT was significantly lower in Group S than Group C on POD 1, 2 and 3. Conclusions: Steroid pretreatment before implantation of the stent graft reduces the early postoperative inflammatory response after EVAR, without increasing postoperative infection. (This is a translation of Jpn J Vasc Surg 2015; 24: 861-865.).

Operando Measurement of Solid Electrolyte Interphase Formation at Working Electrode of Li-Ion Battery by Time-Slicing Neutron Reflectometry.

We report the first operando measurement of solid electrolyte interphase (SEI) formation at an electrode using in situ neutron reflectometry. The results revealed the growth of the SEI and intercalation of ions during the charge reaction. Furthermore, we propose a way of evaluating the charge used for the SEI formation.

Effect of the septal adjustment technique for tricuspid annuloplasty with an MC3 ring.

OBJECTIVES: Functional tricuspid regurgitation (FTR) is a significant negative prospective factor for long-term survival in patients with mitral valve disease. Tricuspid annuloplasty (TAP) for FTR is recommended as a concomitant procedure during left-sided valvular surgery. The MC3 annuloplasty ring is designed to restore the dilated tricuspid annulus to its natural three-dimensional shape, but selection of the optimal ring size during TAP is sometimes difficult. One solution is the septal adjustment technique (SAT), in which the point of fixation of the septal portion to the septal annulus is adjusted under confirmation with the water test. Here, we evaluated early outcomes with this new technique. METHODS: Between January 2008 and September 2014, 56 patients (mean age 67.6 ± 9.0 years, male/female 28/28) with FTR underwent TAP with an MC3 ring. We retrospectively compared early outcomes, including mortality, morbidity and postoperative residual tricuspid regurgitation (TR), between patients undergoing TAP with the SAT (n = 19, Group A) and those undergoing TAP with the conventional technique (n = 37, Group C). RESULTS: Although preoperative TR grade was significantly higher in Group A than Group C (3.2 ± 0.6 vs. 2.8 ± 0.6, p = 0.032), postoperative TR grade was significantly lower in Group A than Group C (0.9 ± 0.6 vs. 1.4 ± 0.8, p = 0.039), and TR grade was significantly decreased in Group A compared to Group C (2.2 ± 0.9 vs. 1.4 ± 0.8, p = 0.004). TR area reduction was significantly larger in Group A than in Group C (5.21 ± 2.34 vs. 2.85 ± 3.09, p = 0.006). CONCLUSIONS: The SAT for TAP with an MC3 ring provided better control of postoperative TR than the conventional technique.

[Staged operation of aortic valve stenosis with concomitant sigmoid colon cancer by minimally invasive cardiac surgery; report of a case].

Severe aortic stenosis was found by preoperative echocardiography in a 79-year-old female patient with sigmoid colon cancer. Staged operation was planned. First, bioprosthetic aortic valve replacement was performed by minimally invasive cardiac surgery. She underwent concomitant colostomy to avoid malnutrition which may have occurred in case of colon obstruction. On 25th day after cardiac surgery, curative sigmoidectomy was performed. One year after the operation, she is doing well without any major complications.

Surgical treatment for right aortic arch with Kommerell's diverticulum.

Kommerell's diverticulum causes compression of the esophagus between the aberrant origin of the left subclavian artery and ascending aorta, leading to dysphagia or dyspnea. We describe 3 cases of successful surgical treatment of right aortic arch with Kommerell's diverticulum and aberrant origin of the left subclavian artery, using a right anterolateral partial sternotomy. This allows both resection of the Kommerell's diverticulum as well as reconstruction of the aberrant origin of the left subclavian artery anatomically.

Thoracic endovascular repair for aorto-esophageal fistula in patients with esophageal carcinoma: report of 3 cases.

Aorto-esophageal fistula (AEF) is a rare complication of esophageal carcinoma. Left untreated, it may be lethal due to massive upper gastrointestinal bleeding, while open thoracic surgery is associated with high operative mortality and morbidity. In contrast, thoracic endovascular aortic repair (TEVAR) for AEF is less invasive than open thoracic surgery. Here, we report 3 successful cases of AEF with esophageal carcinoma treated using TEVAR under local anesthesia in the emergent or urgent phase. General condition of all the patients was dramatically improved, but 1 patient with exsanguinations developed infection of the implanted stent-graft and died due to sepsis. The other 2 patients were treated before esophageal bleeding and remained alive for 1 year without infection. The TEVAR should be considered as early as possible in patients with advanced esophageal carcinoma receiving radiation or chemotherapy who develop early signs of AEF such as symptoms of chest discomfort or descending aortic irregularity on computed tomography scan.

Antero-lateral partial sternotomy for extensive thoracic aortic aneurysm.

OBJECTIVES: Surgical strategies for patients with aortic arch aneurysm extending to the descending aorta remain controversial. The antero-lateral partial sternotomy (ALPS) approach has been developed as a less invasive alternative single-stage strategy for extensive thoracic arch aneurysm (ETAA). METHODS: From September 2007 to April 2011, 18 patients underwent elective total arch replacement for ETAA by the ALPS approach (ALPS group). In this approach, a skin incision was made from the bottom of the xiphoid to the anterior axillary line at the third intercostal space with a convex curved line. The thorax was entered through the third intercostal space and a partial lower sternotomy was done. Surgical outcomes were compared with those of 22 patients with ETAA who underwent elective total arch replacement by median sternotomy alone (MS) with regard to the level of distal anastomosis, postoperative complications and mortality. RESULTS: In the ALPS group, no hospital mortality occurred and one patient experienced pneumonia. No significant difference between the ALPS and MS groups was seen in operative time (384.1 ± 41.6 min vs 402.3 ± 85.3 min P = 0.423) and cardiopulmonary bypass time (220.8 ± 47.1 min vs 236.9 ± 45.4 min P = 0.286). In contrast, distal anastomosis was at a significantly lower vertebral level in the ALPS than in the MS group (5.5 ± 0.4 vs 4.3 ± 0.9, respectively: P < 0.0001). CONCLUSIONS: The ALPS approach provides good surgical exposure for distal aortic arch aneurysms extending to the descending aorta and ensures the accurate reconstruction of the distal anastomosis without major complications.