Collapse-related traumatic intracranial hemorrhage following out-of-hospital cardiac arrest: A multicenter retrospective cohort study.

Background: Sudden loss of consciousness as a result of cardiac arrest can cause severe traumatic head injury. Collapse-related traumatic intracranial hemorrhage (CRTIH) following out-of-hospital cardiac arrest (OHCA) may be linked to poor neurological outcomes; however, there is a paucity of data on this entity. This study aimed to investigate the frequency, characteristics, and outcomes of CRTIH following OHCA. Methods: Adult patients treated post-OHCA at 5 intensive care units who had head computed tomography (CT) scans were included in the study. CRTIH following OHCA was defined as a traumatic intracranial injury from collapse due to sudden loss of consciousness associated with OHCA. Patients with and without CRTIH were compared. The primary outcome assessed was the frequency of CRTIH following OHCA. Additionally, the clinical features, management, and consequences of CRTIH were analyzed descriptively. Results: CRTIH following OHCA was observed in 8 of 345 enrolled patients (2.3%). CRTIH was more frequent after collapse outside the home, from a standing position, or due to cardiac arrest with a cardiac etiology. Intracranial hematoma expansion on follow up CT was seen in 2 patients; both received anticoagulant therapy, and one required surgical evacuation. Three patients (37.5%) with CRTIH had favorable neurological outcomes 28 days after collapse. Conclusions: Despite its rare occurrence, physicians should pay special attention to CRTIH following OHCA during the post-resuscitation care period. Larger prospective studies are warranted to provide a more explicit picture of this clinical condition.

D-dimer measurement is useful irrespective of time from the onset of acute aortic syndrome symptoms.

BACKGROUND: In acute aortic syndrome (AAS) screening, D-dimer is a well-established biomarker whose usefulness has been scarcely studied with respect to its measurement timing. We aimed to evaluate the effectiveness of D-dimer-based AAS screening focused on the time interval between AAS onset and D-dimer measurement. METHODS: We retrospectively analyzed consecutive patients diagnosed with AAS who visited our hospital between 2011 and 2021. For the primary analysis, we divided patients according to the quartiles of the time interval between AAS symptom onset and D-dimer measurement. D-dimer level ≥ 0.5 µg/mL and age-adjusted D-dimer ≥ [age (years) × 0.01] µg/mL (minimum of 0.5 µg/mL) were defined as positive. The primary endpoint was the comparative ability of D-dimer to detect AAS within and between each time quartile. In an exploratory secondary analysis, we reported patient and AAS characteristics in the subgroup of patients who underwent repeat D-dimer measurement within 48 h of the first D-dimer measure. RESULTS: The 273 AAS patients were divided into four groups based on quartiles of the time interval (Group 1, ≤1 h; Group 2, 1-2 h; Group 3, 2-5 h; and Group 4, >5 h). There were no significant differences in D-dimer levels or in the proportions with positive D-dimer (Group 1: 97%, Group 2: 96%, Group 3: 99%, Group 4: 99%; P = 0.76) or positive age-adjusted D-dimer (Group 1: 96%, Group 2: 90%, Group 3: 96%, Group 4: 97%; P = 0.32) between the groups. Of the 147 patients who had D-dimer re-measured, nine had negative D-dimer levels on either the primary or secondary measurement. Of these nine patients, eight had AAS with a thrombosed false lumen and one with a patent false lumen had a short length of dissection. In all nine patients, D-dimer levels remained low (maximum of 1.4 µg/mL). CONCLUSION: D-dimer levels were elevated from the early stages of AAS. The clinical utility of D-dimer is not affected by the time interval from AAS onset to D-dimer measurement, but rather is influenced by AAS characteristics.

Decreased numbers of gastric, colorectal, lung, and breast cancer surgeries performed in 17 cancer-designated hospitals in Gunma Prefecture of Japan during the COVID-19 pandemic.

PURPOSE: This study aims to clarify the influence of the COVID-19 pandemic on cancer surgery in Gunma Prefecture. METHODS: A total of 9839 cases (1406 gastric cancer, 3569 colorectal cancer, 1614 lung cancer, and 3250 breast cancer) from 17 hospitals in Gunma Prefecture were investigated. We compared the number of surgical cases, proportion of cases found by screening, and cStage at the time of the first visit by month in 2020 and 2021 with those in 2019. RESULTS: The rate of decline in cancer surgery was 8.9% in 2020 compared with 2019 (p = 0.0052). Compared with the same month of 2019, in some months of 2020 and 2021, significant decreases were observed in the number of surgeries for gastric and colorectal cancer, the percentage of surgical cases detected by screening in all four cancers, and the proportion of cancers with a relatively early cStage in gastric and breast cancer. CONCLUSIONS: The number of surgical cases of the four cancer types detected by cancer screening decreased in Gunma Prefecture owing to the influence of the COVID-19 pandemic. Furthermore, for some cancer types, the number of operations performed in patients with early-stage cancer is also decreased.

Blood cultures should be collected for acute cholangitis regardless of severity.

BACKGROUND: Despite the high frequency of bacteremia in acute cholangitis, the indications for blood cultures and the relationship between the incidence of bacteremia and severity of acute cholangitis have not been well established. This study examined the association between the 2018 Tokyo Guidelines (TG18) severity grading for acute cholangitis and incidence of bacteremia to identify the need for blood cultures among patients with acute cholangitis in each severity grade. METHODS: Patients with acute cholangitis who visited our emergency department between 2019 and 2020 were retrospectively investigated. Patients administered antibiotics within 48 h of hospital arrival, whose prothrombin time-international normalized ratios were not measured, or who were suspected of false bacteremia were excluded. RESULTS: Out of the included 358 patients with acute cholangitis, blood cultures were collected from 310 (87%) patients, of which 148 (48%) were complicated with bacteremia. As the TG18 severity grading increased, the frequency of bacteremia increased (Grade I, 35% [59/171]; Grade II, 59% [48/82]; Grade III, 74% [42/57]; P <0.001). Agreement with the TG18 diagnostic criteria (unfulfilled, suspected, or definite) was not different between patients with and without bacteremia; however, 36% (14/39) of the patients with "unfulfilled" criteria were complicated with bacteremia. CONCLUSIONS: As the severity of acute cholangitis increased, the frequency of bacteremia increased; however, the incidence of bacteremia was high even in mild cases and cases that did not meet the TG18 diagnostic criteria. Blood cultures should be collected regardless of the severity of acute cholangitis for patients who visit the emergency department.

Potential of unenhanced computed tomography as a screening tool for acute aortic syndromes.

AIMS: Contrast-enhanced computed tomography (CE-CT) is the gold standard for diagnosing acute aortic syndromes (AAS). Unenhanced computed tomography (unenhanced-CT) also provides specific findings for AAS; however, its diagnostic ability is not well discussed. This study aims to evaluate the potential of unenhanced-CT as an AAS screening tool. METHODS AND RESULTS: We retrospectively examined AAS patients who visited our hospital between 2011 and 2021 to validate the diagnostic value of unenhanced-CT alone and along with the aortic dissection detection risk score (ADD-RS) plus D-dimer. Acute aortic syndrome was assessed as detectable using unenhanced-CT with any of the following findings: pericardial haemorrhage, high-attenuation haematoma, and displacement of intimal calcification or a flap. Of the 316 AAS cases, 292 (92%) were detectable with unenhanced-CT. Twenty-four (8%) cases undetectable with unenhanced-CT involved younger patients [median (interquartile range), 45 (42-51) years vs. 72 (63-80) years, P < 0.001] and patients more frequently complicated with a patent false lumen (79% vs. 42%, P < 0.001). Acute aortic syndrome-detection rate with unenhanced-CT increased with age, reaching 98% (276/282) in those ≥50 years of age and 100% (121/121) in those ≥75 years of age. With the ADD-RS plus D-dimer, there was only one AAS case undetectable with unenhanced-CT among patients ≥50 years of age, except for cases with the ADD-RS ≥1 plus D-dimer levels of ≥0.5 µg/mL. CONCLUSION: Acute aortic syndromes in younger patients and patients with a patent false lumen could be misdiagnosed with unenhanced-CT alone. The combination of the ADD-RS plus D-dimer and unenhanced-CT could minimize AAS misdiagnosis while avoiding over-testing with CE-CT.

Clinical prediction rule is more useful than qSOFA and the Sepsis-3 definition of sepsis for screening bacteremia.

BACKGROUND: Clinical guidelines recommend blood cultures for patients suspected with sepsis and bacteremia. Sepsis-3 task force introduced the new definition of sepsis in 2016; however, the relationship between the Sepsis-3 definition of sepsis and bacteremia remains unclear. This study aimed to investigate how to detect patients who need blood cultures. METHODS: Consecutive patients who visited the emergency department in our hospital with suspected symptoms of bacterial infection and with collected blood culture were retrospectively examined between April and September 2019. The relationship between bacteremia and Sepsis-3 definition of sepsis, and the relationship between bacteremia and clinical scores (quick-Sequential Organ Failure Assessment [qSOFA], systematic inflammatory response syndrome [SIRS], and Shapiro's clinical prediction rule) were investigated. In any scores used, ≥2 points were considered positive. RESULTS: Among the 986 patients who met the inclusion criteria, 171 (17%) were complicated with bacteremia and 270 (27%) were patients with sepsis. Sepsis was more frequent (61% vs. 20%, P < 0.001) and all clinical scores were more frequently positive in patients with bacteremia than in those without (qSOFA, 23% vs. 9%; SIRS, 72% vs. 58%; Shapiro's clinical prediction rule, 88% vs. 49%; P < 0.001). Specificity to predict bacteremia was high in sepsis and positive qSOFA (0.80 and 0.91, respectively), whereas sensitivity was high in positive SIRS and Shapiro's clinical prediction rule (0.72 and 0.88, respectively); however, no clinical definitions and scores had both high sensitivity and specificity. The area under the receiver operating characteristic curves were 0.59 (95% confidence interval, 0.55-0.64), 0.60 (0.56-0.65), and 0.78 (0.74-0.82) in qSOFA, SIRS, and Shapiro's clinical prediction rule, respectively. CONCLUSION: Blood cultures should be obtained for patients with sepsis and positive qSOFA because of its high specificities to predict bacteremia; however, because of low sensitivities, Shapiro's clinical prediction rule can be more efficiently used for screening bacteremia.

Extended total gastrectomy after nivolumab for unresectable multivisceral invasive gastric cancer.

BACKGROUND: Chemotherapy has been considered the main treatment for stage IV gastric cancer (GC). However, advances in chemotherapy have provided new clinical approaches, permitting conversion surgery with the aim of R0 resection after resolving unresectability issues. CASE PRESENTATION: A 70-year-old man with gastric cancer invading the pancreatic tail and spleen and with periaortic lymph-node enlargement was admitted to our hospital. After 24 courses of nivolumab as third-line chemotherapy, periaortic lymph-node enlargement was resolved, and conversion surgery was planned. Intraoperatively, we found no peritoneal metastasis, but the distal pancreas, splenic hilum, and transverse colon were adhered to the gastric body. Therefore, we performed D2 total gastrectomy with distal pancreatosplenectomy and partial transverse colectomy. The pathological diagnosis was type III moderately differentiated tubular adenocarcinoma (tub2) with signet ring cells, stage ypT1b (SM), ly0, and v0. The pathological proximal and distal tumor margins were negative. One lymph-node metastasis was observed (No. 4d; 1/23). Postoperatively, no recurrence was observed over 7 months, without adjuvant chemotherapy. CONCLUSIONS: Nivolumab may allow R0 resection in patients with unresectable gastric cancer. Conversion surgery should be considered even after third-line nivolumab treatment.

Left subclavian and right femoral vein thrombosis in a pregnant patient with antithrombin deficiency.

Pregnancy is well-known risk factor for deep vein thrombosis (DVT), which usually occurs during the third trimester and in the left-sided lower extremity. We present a case of left subclavian and right femoral vein thrombosis in a pregnant woman with a gestational age of 10 weeks. A 39-year-old woman visited the emergency department complaining of acute pain and swelling of the left upper arm and right lower extremity. She showed swelling of the left upper arm and right lower extremity and a low antithrombin level of 40%. Ultrasound examination showed right femoral and left subclavian vein thrombosis. Her DVTs were treated with unfractionated heparin. Five months later, she received a cesarean delivery with intravenous unfractionated heparin and antithrombin replacement to prevent DVT, and she successfully gave birth. A genetic test for antithrombin deficiency confirmed hereditary antithrombin deficiency. DVT during pregnancy can occur in an upper extremity and at multiple sites. An undiagnosed coagulation disorder magnifies the risk of DVT in pregnant patients. We should examine all extremities for which there are complaints of pain and swelling with suspicion of DVT and consecutively search for an underlying coagulation disorder in pregnant patients with unusual clinical features of DVT. .

Refractory hypotension due to Nivolumab-induced adrenal insufficiency.

Nivolumab, a new immune checkpoint inhibitor that has been found to improve outcomes for patients with some advanced cancers, is being increasingly used. Immune checkpoint inhibitors can cause immune-related adverse events, including dermatitis, enterocolitis, hepatitis and hypophysitis, but adrenal insufficiency rarely occurs. We present a case of Nivolumab-induced adrenal insufficiency in a man who complained of refractory hypotension. A 52-year-old man with non-small cell lung cancer visited our emergency department complaining of fatigue and diarrhea. He had received Nivolumab every 2 weeks as third-line therapy for a total of 10 times. On arrival, his vital signs revealed shock: blood pressure, 68/48 mmHg; heart rate, 141 beats per minutes. Laboratory examination showed severe hemoconcentration with a hemoglobin level of 19.9 g/dL, normal electrolyte levels and hyperglycemia. We started intravenous infusion of 4.5 L of extracellular fluid, but his vital signs remained unstable. After admission, endocrine examination revealed abnormally low values of serum cortisol (4.86 µg/dL) and ACTH (<1.0 pg/mL), which had been normal at 2 months before admission (21.14 µg/dL and 20.1 pg/mL, respectively). We therefore made a diagnosis of adrenal insufficiency induced by Nivolumab and administered 100 mg hydrocortisone succinate sodium intravenously. He recovered soon after hydrocortisone replacement therapy. Nivolumab is a new immune checkpoint inhibitor and general physicians are not familiar with it. However, adverse events caused by Nivolumab, especially adrenal insufficiency, can lead to serious adverse outcomes if overlooked. We should recognize Nivolumab-induced adrenal insufficiency and administer a glucocorticoid immediately in cancer patients treated with immune checkpoint inhibitors.

Epoetin ß pegol (continuous erythropoietin receptor activator, CERA) is another choice for the treatment of anemia in myelodysplastic syndrome: a case report.

BACKGROUND: In most patients, anemia is present when myelodysplastic syndrome is diagnosed. Although darbepoetin α is the first-choice supportive therapy for low-risk myelodysplastic syndrome, half of all patients develop a loss of response to darbepoetin α within 12 months. However, few reports have described supportive therapy after the loss of response to darbepoetin α. CASE PRESENTATION: We herein present a case involving a 65-year-old Japanese woman with low-risk myelodysplastic syndrome whose erythropoiesis-stimulating agent treatment was switched from darbepoetin α to epoetin ß pegol (continuous erythropoietin receptor activator) to treat transfusion-dependent anemia. The frequent transfusions required to treat the anemia resulted in transfusion-associated circulatory overload. The transfusion-dependent anemia was initially treated with darbepoetin α, which negated the requirement for transfusion. However, after 12 months of darbepoetin α therapy, the hemoglobin concentration sharply declined. We switched her therapy from darbepoetin α to continuous erythropoietin receptor activator to avoid transfusion. After initiation of continuous erythropoietin receptor activator therapy, the hemoglobin concentration gradually increased and transfusion was not required. At the time of writing, no progression of the anemia had occurred. CONCLUSIONS: Although darbepoetin α is the first-choice supportive therapy for low-risk myelodysplastic syndrome, continuous erythropoietin receptor activator might be considered the second-choice therapy.

Unusual underlying disorder for pulmonary embolism: Cold agglutinin disease.

Cold agglutinin disease (CAD) is a form of autoimmune hemolytic anemia caused by cold-reacting autoantibodies. The manifestations of CAD are commonly anemia, acrocyanosis, and fatigue caused by hemolysis and agglutination of red blood cells (RBCs) at a temperature lower than normal body temperature. We report a case of CAD presenting with pulmonary embolisms in an 86-year-old man. The patient visited our emergency department complaining of acute chest pain and respiratory distress. Laboratory data showed decreased RBC and hematocrit and markedly elevated mean corpuscular hemoglobin (MCH) and MCH concentration (MCHC). A contrast-enhanced computed tomographic scan demonstrated bilateral massive pulmonary embolisms. After admission, diagnosis of CAD was made on the basis of a high cold agglutinin titer without other factors of coagulation. CAD can contribute to the onset of pulmonary embolisms. It is necessary to incubate blood samples at 37 °C when laboratory data show markedly elevated MCH and MCHC and to consider the presence of cold agglutinins as an underlying disorder for the formation of venous thrombosis. .

Unusual Initial Manifestation of Acquired Hemophilia A: A Normal Activated Partial Thromboplastin Time, Intramuscular Hematoma and Cerebral Hemorrhage.

We herein present a case of acquired hemophilia A with a normal activated partial thromboplastin (aPTT), intramuscular hematoma and cerebral hemorrhage occurring in a 73-year-old man. The patient visited our emergency department with gait disturbance, pain and swelling in his right leg. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed intramuscular hematoma and intracranial hemorrhage. The results of initial coagulation studies were normal, but repeated coagulation studies revealed an isolated prolongation of the aPTT. Additional laboratory tests confirmed the diagnosis of acquired hemophilia A. If the initial aPTT is normal, we should therefore repeat the aPTT and also perform other coagulation studies including a mixing study, factor VIII level and inhibitor, to investigate the underlying diseases in elderly patients with spontaneous hemorrhaging of unknown etiology.

Sealing Effect of Cross-Linked Gelatin Glue in the Rat Lung Air Leak Model.

BACKGROUND: Air leak is a common problem in pulmonary surgical procedures. In this study, we evaluated the efficacy and safety of gelatin glue (cross-linked with glutaraldehyde) in a rat model of lung air leak. METHODS: A model of pulmonary fistula was created in the rat lung with the use of a needle. The fistula was then sealed with either gelatin glue (group A), fibrin glue (group B), or fibrin glue with a polyglycolic acid sheet (group C). The seal breaking pressures were measured for each group, and the results were compared. To assess the biocompatibility of the gelatin glue, a model of lung damage was created with incision, and the gelatin glue was applied to seal the wound. Histologic analysis was then performed on the lung tissue. RESULTS: The seal breaking pressure in group A (47.88 ± 6.69 mm Hg) was significantly higher than that in group B (24.67 ± 3.24 mm Hg, p = 0.0302) or group C (28.67 ± 3.55 mm Hg, p = 0.0406). Histologically, the gelatin glue adhered firmly to the lung surface, and only localized tissue inflammation was observed. CONCLUSIONS: The sealing effect of gelatin glue was superior to that of fibrin glue, with or without a polyglycolic acid sheet. In addition, the gelatin glue only caused mild inflammation of the lung and was absorbed without any adverse foreign body response. These findings suggest that gelatin glue may be a therapeutically effective biomaterial for sealing lung wounds and restoring respiratory function.

Spontaneous isolated left gastric artery dissection: unusual visceral artery dissection.

Case: A 51-year-old woman visited our emergency department complaining of acute onset of upper abdominal pain and nausea. Abdominal contrast-enhanced computed tomography showed an isolated left gastric artery dissection and pseudoaneurysm. After conservative management for 6 days, endovascular embolization was carried out for treatment of the pseudoaneurysm. Spontaneous dissection of a visceral artery rarely occurs in the case of a left gastric artery. Outcome: Contrast-enhanced computed tomography is essential to make an accurate diagnosis and establish a therapeutic strategy. Conclusion: We should consider the occurrence of minor visceral artery dissection if a patient has acute abdominal pain without other obvious causes.

Nutritional parameters affecting severity of pneumonia and length of hospital stay in patients with pneumococcal pneumonia: a retrospective cross-sectional study.

BACKGROUND: Pneumococcal pneumonia is the most common form of community-acquired pneumonia (CAP). Although a pneumococcal conjugate vaccine has contributed to a reduction in the incidence of pneumococcal pneumonia among older children and adults, no significant decrease in the incidence has been observed among persons aged ≥65 years. A low body mass index and hypoalbuminemia are common in Japanese patients with CAP, but the association of other nutritional parameters with the severity of pneumonia or length of hospital stay in patients with pneumococcal pneumonia is unclear. METHODS: Fifty-seven previously healthy inpatients who presented with pneumococcal pneumonia were divided into two groups: those aged ≥65 years (n = 36) and those aged <65 years (n = 21). Patients' characteristics (the Confusion, Urea, Respiratory rate, Blood pressure, age >65 years (CURB-65) score), the pneumonia severity index (PSI), and inflammatory and metabolic nutritional parameters were compared between the two groups. RESULTS: The older group showed significantly lower serum albumin and cholinesterase (ChE) levels. Multivariate linear regression analysis revealed that the PSI was positively correlated with age in both groups. In the younger age group, both the CURB-65 score and PSI showed significant negative correlations with the serum ChE level, and there was a significant negative correlation between the length of stay and serum total cholesterol (T-cho) level. In the older group, the fasting period, lymphocyte count, and age showed significant positive correlations with the length of stay. There was a significant negative correlation between the length of stay and serum albumin level, but no correlation with the serum ChE or T-cho levels, in the older patients. CONCLUSIONS: Our findings suggest that in patients aged <65 years, age and serum ChE and T-cho levels were associated with both the severity of pneumococcal pneumonia and length of stay. In contrast, the length of stay in older patients was associated with multiple factors that differed from those in younger patients. These differences may reflect age-related immunosenescence in older patients and a greater effect of serum ChE and T-cho levels on immunity in younger patients.