Effectiveness of vacuum-assisted wound closure and mesh-mediated fascial traction in open abdomen management.

PURPOSE: To determine the effectiveness of vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) in patients undergoing open abdomen management (OAM). METHODS: Data from cases with OAM for at least five days who were admitted to our institution between January 2011 and December 2020 were included. We compared the patient's age, sex, medical history, indication for initial surgery, APACHE II scores, indication for OAM, operative time, intraoperative blood loss, intraoperative transfusion, success of primary fascial closure (rectus fascial closure and bilateral anterior rectus abdominis sheath turnover flap method), success of planned ventral hernia, duration of OAM, and in-hospital mortality between patients undergoing VAWCM (VAWCM cases, n = 27) and vacuum-assisted wound closure (VAWC) alone (VAWC cases, n = 25). RESULTS: VAWCM cases had a significantly higher success rate of primary fascial closure (70% vs. 36%, p = 0.030) and lower in-hospital mortality (26% vs. 72%, p = 0.002) than VAWC cases. A multivariate logistic regression analysis showed that VAWCM was an independent factor influencing in-hospital mortality (odds ratio, 0.14; 95% confidence interval: 0.04-0.53; p = 0.004). CONCLUSION: VAWCM is associated with an increased rate of successful primary fascial closure and may reduce in-hospital mortality.

Validation of a surgical difficulty grading system in laparoscopic cholecystectomy for acute cholecystitis.

BACKGROUND: The surgical difficulty of laparoscopic cholecystectomy (LC) for acute cholecystitis varies from case to case, and appropriate intraoperative evaluation would help prevent bile duct injury (BDI). METHODS: We analyzed 178 patients who underwent LC for acute cholecystitis. Expert surgeons and trainees individually evaluated the surgical difficulty. The inter-rater agreement was analyzed using Conger's κ and Gwet's agreement coefficient (AC). Furthermore, we analyzed the predictive surgical difficulty item for performing subtotal cholecystectomy (STC). RESULTS: Regarding the inter-rater agreement between expert surgeons and trainees, 15 of the 17 surgical difficulty items had a Gwet's AC of 0.5 or higher, indicating "moderate" agreement or higher. Furthermore, the highest and total surgical difficulty scores were deemed "substantial" agreement. Scarring and dense fibrotic changes around the Calot's triangle area with easy bleeding with/without necrotic changes were predictive of whether STC should be performed. CONCLUSIONS: This surgical difficulty grading system is expected to be a tool that can be used by any surgeon with LC experience. STC should be performed to prevent BDI according to the changes around the Calot's triangle area.

Rapid Recovery in a Patient with Severe COVID-19 after a Low-Load, High-Frequency Rehabilitation Program Using an Ergometer in the Supine Position.

BACKGROUND: Rehabilitation therapy for patients with severe coronavirus disease 2019 (COVID-19) is crucial; however, studies regarding rehabilitation strategies for intensive care unit (ICU) patients with COVID-19 are limited. We report a case of severe COVID-19 in an ICU patient whose physical function and basic movement ability rapidly improved after the initiation of active aerobic exercise in the supine position. CASE: A 70-year-old man with hypertension and obesity was admitted to the ICU and managed with a ventilator because of severe COVID-19. Physical therapy started on postadmission day 34. Problems encountered during physical therapy included low saturation of percutaneous oxygen (SpO2; <90%), dyspnea with a light exercise load, advancing muscle weakness, and endurance decline. The rehabilitation program included getting out of bed and resistance training of the upper and lower limbs twice daily while maintaining SpO2 at ≥90%. After ventilator weaning, we initiated aerobic training using a supine ergometer with varying load volume. On discharge from the ICU on postadmission day 45, the patient's physical function (handgrip strength, Medical Research Council score, and Borg scale) and basic movement ability (Functional Status Score for ICU) rapidly improved. CONCLUSION: Rehabilitation therapy involving aerobic cycling training based on a quantitative load setting may be effective in treating COVID-19.

Machine Learning Prediction for Supplemental Oxygen Requirement in Patients with COVID-19.

BACKGROUND: The coronavirus disease (COVID-19) poses an urgent threat to global public health and is characterized by rapid disease progression even in mild cases. In this study, we investigated whether machine learning can be used to predict which patients will have a deteriorated condition and require oxygenation in asymptomatic or mild cases of COVID-19. METHODS: This single-center, retrospective, observational study included COVID-19 patients admitted to the hospital from February 1, 2020, to May 31, 2020, and who were either asymptomatic or presented with mild symptoms and did not require oxygen support on admission. Data on patient characteristics and vital signs were collected upon admission. We used seven machine learning algorithms, assessed their capability to predict exacerbation, and analyzed important influencing features using the best algorithm. RESULTS: In total, 210 patients were included in the study. Among them, 43 (19%) required oxygen therapy. Of all the models, the logistic regression model had the highest accuracy and precision. Logistic regression analysis showed that the model had an accuracy of 0.900, precision of 0.893, and recall of 0.605. The most important parameter for predictive capability was SpO2, followed by age, respiratory rate, and systolic blood pressure. CONCLUSION: In this study, we developed a machine learning model that can be used as a triage tool by clinicians to detect high-risk patients and disease progression earlier. Prospective validation studies are needed to verify the application of the tool in clinical practice.

Use of a Compact, Lightweight X-ray Unit to Reduce the Risk of Five Invasive Procedures in the Emergency Room.

BACKGROUND: Many invasive procedures performed in the emergency room (ER) have potential risks and complications. Because of their limitations, in particular size, portable X-ray devices are generally not used during such procedures. However, miniaturized units enable physicians to obtain X-ray images without assistance. METHODS: We developed a safe, compact, and lightweight X-ray unit that was used during five invasive procedures in the ER. In all procedures, a chest X-ray image was obtained, to confirm the utility of the unit. RESULTS: Case 1 (central venous catheter placement): After needle and guidewire insertion and catheter placement, the location of the catheter could be confirmed. Case 2 (chest tube insertion): During insertion of a chest tube into the pleural space, the tip of the thoracic tube was confirmed to be at the correct location. Case 3 (percutaneous tracheostomy or cricothyroidotomy): After needle and guidewire insertion, the guidewire was visualized in the right main bronchus and was inserted into the trachea. Case 4 (resuscitative endovascular aortic balloon of the aorta): The captured image revealed that the catheter was located in zone I before balloon inflation. Case 5 (Sengstaken-Blakemore tube): The image revealed that the balloon was located in the stomach. CONCLUSIONS: The portable X-ray unit improved medical safety during invasive procedures frequently performed in the ER.

Nonocclusive mesenteric ischemia associated with a hyperosmolar hyperglycemic state: Hepatic portal venous gas as an indicator of mesenteric ischemia.

BACKGROUND: The diagnosis of nonocclusive mesenteric ischemia (NOMI) is always challenging in critically ill patients. Herein, we aimed to report a case of NOMI associated with a hyperosmolar hyperglycemic state (HHS). A small amount of hepatic portal venous gas (HPVG) triggered the diagnosis of NOMI. CASE PRESENTATION: A 77-year-old man was transferred due to shock and disorder of consciousness. He was diagnosed with an HHS. We suspected intestinal ischemia due to a small amount of HPVG revealed by computed tomography (CT). Peritoneal signs were revealed after treatment for the HHS. Computed tomography was carried out again 5 h after admission, which showed a large amount of HPVG, remarkable bowel dilatation, and pneumatosis intestinalis. We performed an emergency laparotomy and resected the small bowel necrosis resulting from NOMI. CONCLUSION: An HHS can cause NOMI, and the presence of HPVG on CT is an important finding that suggests mesenteric ischemia, even in small amounts.

Early automated infrared pupillometry is superior to auditory brainstem response in predicting neurological outcome after cardiac arrest.

AIM: Assessment of brainstem function plays a key role in predicting the neurological outcome after cardiac arrest. However, the relationship of the two quantitative brainstem assessment methods-automated infrared pupillometry (AIP) and auditory brainstem response (ABR)-with neurological prognoses remains unclear. This study compares the prognostic value of AIP and ABR after cardiopulmonary arrest. METHODS: This retrospective observational study included 124 comatose patients after cardiopulmonary arrest. ABR and AIP measurements were performed simultaneously within 72 h after return of spontaneous circulation. Neurological outcome was assessed at discharge by estimating the cerebral performance category (CPC) score; favourable neurological outcome (CPC score, 1-2) or poor neurological outcome (CPC score, 3-5). The correlation of each AIP parameter and ABR I-V wave latency was tested using Pearson's product moment correlation coefficient, and the prognostic value was compared using the area under the receiver operating characteristics curve (AUC). RESULTS: Pupillary light reflex (PLR) was not detected in 69 patients, and ABR wave V was not detected in 47 patients. All these patients had poor neurological outcome. Among those whose PLR and ABR could be measured, each AIP parameter had a tendency to be correlated with ABR I-V wave latency. Pupil constriction velocity provided the greatest AUC (0.819), with 81% sensitivity and 77% specificity. ABR I-V wave latency provided extremely low AUC (0.560). CONCLUSIONS: Although AIP and ABR were correlated, the AIP measures were superior in predicting the neurological outcome after cardiac arrest as compared with the ABR measures.