Factors Associated with Favorable Outcomes in Cardiac Arrest and Target Temperature Management.

Current guidelines strongly recommend providing targeted temperature management (TTM) after cardiac arrest, but hypothalamic dysregulation may confound TTM's impact on a patient's ultimate outcome. Although time to reach target temperature has largely been viewed as a process measure for TTM protocols, the difference between initial presenting temperature and target temperature (Δ-temperature) may be a potential surrogate marker of hypothalamic dysregulation. We performed a retrospective observational study to explore whether Δ-temperature was associated with neurologic outcomes and mortality. We included 86 patients (53 with out-of-hospital cardiac arrest [OHCA] and 33 with in-hospital cardiac arrest [IHCA]) in our analysis; more than half of the patients were cooled to 33°C (56.9% in OHCA and 57.6% in IHCA). In univariate logistic regression analysis, Δ-temperature alone did not appear to be statistically associated with mortality or neurologic outcomes regardless of target temperature. In exploratory analysis, longer time from TTM initiation-to-target was associated with worse neurological outcomes in the 33°C target (odds ratio = 0.996, 95% confidence interval = 0.992-1.000). Further research investigating the impact of hypothalamic dysregulation and Δ-temperature as well as the rate of cooling may be warranted to elucidate additional factors contributing to outcomes after cardiac arrest. In addition, our study population was noted to have a higher proportion of Asians and Native Hawaiians/Pacific Islanders, with a potential disparity in outcomes. Future studies may be warranted to ensure generalizability of TTM protocols and findings across populations.

A Case of Tracheo-innominate Artery Fistula after Tracheostomy Successfully Treated with a Covered Stent.

A 78-year-old man underwent a tracheostomy after embolization for a dural arteriovenous fistula. Seventy days after tracheostomy, arterial bleeding appeared through the tracheal stoma. The bleeding stopped spontaneously. However, two days later, arterial bleeding reappeared, and he was diagnosed with a tracheo-innominate artery fistula (TIF). He then underwent urgent endovascular covered stent placement. After the procedure, there was no bleeding. TIF can be a fatal complication after tracheostomy and it is generally treated with open chest surgery. However, a successful endovascular treatment for TIF has recently been reported and may yield better results.

Cefepime-induced neurotoxicity: systematic review.

BACKGROUND: Cefepime-induced neurotoxicity (CIN) has been well acknowledged among clinicians, although there are no clear diagnostic criteria or specific laboratory testing to help with its diagnosis. We aimed to summarize the existing evidence regarding CIN and provide future agendas for research. METHODS: Following the PRISMA Extension for Scoping Reviews, we searched MEDLINE and Embase for all peer-reviewed articles using keywords including 'cefepime', 'neurotoxicity', 'encephalopathy' and 'seizure', from their inception to 20 January 2022. RESULTS: We included 92 articles, including 23 observational studies and 69 cases from case reports and case series, in the systematic review. Among 119 patients with CIN, 23.5% were in the ICU at the time of diagnosis and nearly 90% of the cases showed renal dysfunction.Cefepime overdoses were described in 41%. The median latency period of developing CIN from cefepime initiation was 4 days, and about 12% developed CIN during empirical treatment. CIN patients commonly manifested altered mental status (93%), myoclonus (37%) and non-convulsive seizure epilepticus (28%). A serum cefepime trough level of >20 mg/L would put patients at risk for CIN. CIN-related symptoms were ameliorated in 97.5% by dose reduction or discontinuation of cefepime, with median time to improvement of 3 days. No CIN-associated deaths were reported. CONCLUSIONS: This systematic review summarizes the current evidence and characteristics of CIN. In the current situation where there are no CIN diagnostic criteria and the drug monitoring platform is not routinely available, candidates for cefepime should be carefully selected. Also, based on these findings, it needs to be appropriately dosed to avoid the development of CIN.

Clinical characteristics of BRASH syndrome: Systematic scoping review.

BACKGROUND: Bradycardia, renal failure, atrioventricular (AV) nodal blockade, shock, and hyperkalemia (BRASH) syndrome is a recently-established entity precipitated by medication-induced AV nodal blockade. Despite its serious consequences, including death, clinical presentations, risk factors, and outcomes of the syndrome have not been well defined. We aim to summarize the existing evidence of BRASH syndrome. METHODS: According to the PRISMA Extension for Scoping Reviews, we performed a search on MEDLINE and EMBASE for articles with keywords including"BRASH syndrome" and "bradycardia, renal failure, atrioventricular nodal blockade, shock, and hyperkalemia," from the inception of these databases to March 4, 2022. RESULTS: 34 articles, including one observational study, 15 conference abstracts, and 18 case reports and case series, were included. While most patients were on beta blockers (83.3%) or calcium channel blockers (45.2%), other medications such as amiodarone were identified as precipitating agents. Atropine or glucagon were ineffective in reversing patients' symptoms, and 59.5% required inotropes or chronotropes. 7.1% expired due to BRASH syndrome. CONCLUSIONS: This systematic review summarizes the clinical characteristics of BRASH syndrome. Further studies to identify risks associated with the onset of BRASH syndrome and awareness of the critical syndrome are warranted.

Procalcitonin to Predict Severity of Acute Cholangitis and Need for Urgent Biliary Decompression: Systematic Scoping Review.

Serum procalcitonin (PCT) has been reported as a potential biomarker to predict the severity of acute cholangitis (AC) or the need for urgent biliary decompression. This study aimed to identify and summarize the existing research about serum PCT and the severity of AC, and to find gaps towards which future studies can be targeted. Following the PRISMA extension for scoping reviews, MEDLINE, EMBASE, and Google Scholar were searched for all peer-reviewed articles with relevant keywords including "cholangitis" and "procalcitonin" from their inception to 13 July 2021. We identified six studies. All the studies employed a case-control design and aimed to evaluate the usefulness of serum PCT to predict the severity of AC with key identified outcomes. While the potential cut-off values of serum PCT for severe AC ranged from 1.8-3.1 ng/mL, studies used different severity criteria and the definition of urgent biliary decompression. No studies proposed cut-off PCT values for the need for urgent biliary decompression. This scoping review identified the current level of evidence regarding the usefulness of serum PCT in assessing the severity of AC. Further clinical research is warranted with a focus on standardized outcome measures employing prospective or experimental designs.

Impact of the World Inflammatory Bowel Disease Day and Crohn's and Colitis Awareness Week on Population Interest Between 2016 and 2020: Google Trends Analysis.

Background: More than 6 million people are affected by inflammatory bowel disease (IBD) globally. The World IBD Day (WID, May 19) and Crohn's and Colitis Awareness Week (CCAW, December 1-7) occur yearly as national health observances to raise public awareness of IBD, but their effects are unclear. Objective: The aim of this study was to analyze the relationship between WID or CCAW and the public health awareness on IBD represented by the Google search engine query data. Methods: This study evaluates the impact of WID and CCAW on the public awareness of IBD in the United States and worldwide from 2016 to 2020 by using the relative search volume of "IBD," "ulcerative colitis," and "Crohn's disease" in Google Trends. To identify significant time points of trend changes (joinpoints), we performed joinpoint regression analysis. Results: No joinpoints were noted around the time of WID or CCAW during the study period in the search results of the United States. Worldwide, joinpoints were noted around WID in 2020 with the search for "IBD" and around CCAW in 2017 and 2019 with the search for "ulcerative colitis." However, the extents of trend changes were modest without statistically significant increases. Conclusions: These results posed a question that WID and CCAW might not have worked as expected to raise public awareness of IBD. Additional studies are needed to precisely estimate the impact of health observances to raise the awareness of IBD.

A collaborative educational intervention on procedural sedation and analgesia across the Pacific.

AIM: Worldwide, health-care providers carry out procedural sedation and analgesia (PSA) in the emergency department. However, training opportunities are limited in many Asian countries, including Japan. We formed an educational group consisting of board-certified emergency physicians in the USA and Japanese physicians and developed a PSA training module. The aims of our study were to demonstrate the effectiveness of training and to describe PSA practice in Japan. METHODS: We undertook a pretest of PSA knowledge questions and a retest immediately after the training intervention. We also carried out a survey and asked about participants' PSA practice. The training module consisted of four didactic hours and three simulation and skills laboratory hours. Results of all pre- and post-intervention knowledge questions were analyzed with McNemar's test, and overall scores were analyzed with a paired t-test. RESULTS: One hundred and forty-four health-care providers including 123 physicians, 16 nurses, two pharmacists, and three medical students participated in the training. A total of 119 (83%) completed both the pre- and post-intervention knowledge questions. Before the training, participants scored an average 66% (63%-69%) on the written knowledge test. After the intervention, participants showed significant improvement on the knowledge test (improvement 17%; 14%-20%). Among participants who answered the practice survey, 121 (88%) have undertaken PSA. Only 14 (12%) participants always or often use a continuous capnography for PSA. Only 32 (26.4%) participants undertook pre-PSA systematic evaluation. CONCLUSION: Our educational intervention successfully increased participants' knowledge. Only the minority of health-care providers use capnography routinely for PSA, and pre-PSA evaluation is not commonly carried out.

[A Case of Arteriovenous Malformation of the Parotid Gland Associated with Cowden Disease].

We report a rare case of arteriovenous malformation(AVM)of the parotid gland associated with Cowden disease successfully treated with preoperative embolization followed by surgical removal. A 39-year-old man with a history of Cowden disease presented with a pulsating and growing mass on his left lower jaw. Contrast-enhanced computed tomography(CT)and angiography revealed a high-flow AVM in the deep lobe of the left parotid gland. After intravascular embolization of the feeding arteries, surgery was performed using the NIM-response®3.0, facial nerve monitoring system. The AVM was almost completely removed and the facial nerves were morphologically preserved. Interestingly, the intraoperative findings revealed that the enlarged vasa nervorum of the facial nerve also fed the AVM. Although left facial nerve palsy appeared after the surgery, the nerve function gradually improved over one year. No recurrence of the AVM has been observed for one year.

Characteristic ultrasound features of mucosa-associated lymphoid tissue lymphoma of the salivary and thyroid gland.

CONCLUSION: The characteristic ultrasound appearance of mucosa-associated lymphoid tissue (MALT) lymphoma of the head and neck provides diagnostic information regarding masses or swellings in the head and neck region. OBJECTIVES: There are only a few reports about ultrasound features of malignant lymphoma (ML) of the head and neck. We have noticed that the ultrasound appearances of cases with MALT lymphoma resembled each other even when the appearances of other images like computed tomography were absolutely different. The objective of this study was to delineate the reliability of this characteristic ultrasound appearance of MALT lymphoma of the head and neck. METHODS: The ultrasound examinations of 30 patients with histopathologically proven primary ML of the head and neck (15 cases of MALT) were reviewed. The ultrasound results of each case were independently compared to the results of the histopathological examination. RESULTS: Two ultrasound patterns were observed for MALT lymphoma. The first was characterized by a marked hypoechoic area with interspersed linear echogenic strands (linear echogenic strands pattern), and the second was characterized by multiple, relatively large, hypoechoic segments (segmental pattern). Histopathologically, these patterns could be explained on the basis of the expansion of lymphoma cells demarcated by narrow or wide fibrous bands.

Cyclic AMP responsive element binding proteins are involved in 'emergency' granulopoiesis through the upregulation of CCAAT/enhancer binding protein ß.

In contrast to the definitive role of the transcription factor, CCAAT/Enhancer binding protein α (C/EBPα), in steady-state granulopoiesis, previous findings have suggested that granulopoiesis during emergency situations, such as infection, is dependent on C/EBPß. In this study, a novel lentivirus-based reporter system was developed to elucidate the molecular switch required for C/EBPß-dependency. The results demonstrated that two cyclic AMP responsive elements (CREs) in the proximal promoter region of C/EBPß were involved in the positive regulation of C/EBPß transcription during granulocyte-macrophage colony-stimulating factor (GM-CSF)-induced differentiation of bone marrow cells. In addition, the transcripts of CRE binding (CREB) family proteins were readily detected in hematopoietic stem/progenitor cells. CREB was upregulated, phosphorylated and bound to the CREs in response to GM-CSF stimulation. Retroviral transduction of a dominant negative CREB mutant reduced C/EBPß mRNA levels and significantly impaired the proliferation/differentiation of granulocyte precursors, while a constitutively active form of CREB facilitated C/EBPß transcription. These data suggest that CREB proteins are involved in the regulation of granulopoiesis via C/EBPß upregulation.

A case of hypothyroid Graves' disease following external radiation therapy to the cervical region.

A case of hypothyroid Graves' disease occurred following external radiation therapy to the cervical region is described. Severe hypothyroidism developed in a 56-year-old man 6 months after external radiation therapy for submandibular cancer. Serological evaluation of thyroid autoimmunity revealed the presence of antithyroid antibodies and thyrotropin-binding inhibitory immunogloblins (TBII). Diplopia, limitation of downward gaze, and palpebral edema developed 2 years after levothyroxine replacement therapy. Ocular magnetic resonance imaging revealed marked hypertrophy of the bilateral extraocular muscles with signal hyperintensity on T2-weighted images. This infiltrative ophthalmopathy showed marked improvement after additional treatment with high-dose methylprednisolone and orbital radiation, in parallel with a decrease in TBII. These results suggest that radiation-associated thyroidal injury might be associated with the etiology of hypothyroid Graves' disease.

High-throughput screening for GJB2 mutations--its clinical application to genetic testing in prelingual deafness screening for GJB2 mutations.

OBJECTIVES: Mutations in connexin26 (GJB2) are one of the most frequent causes of prelingual hearing impairment. Several different types of one-base deletions in exon2 were the most common type of GJB2 mutation regardless of ethnicity, including 35delG in American-European populations, 235delC in Japanese population and 167delT in Ashkenazi Jewish population. Various types of one-base substitutions were also considered to be causative mutations of GJB2 associated hearing impairment. This article describes a rapid and high-throughput screening procedure for the detection of one-base deletion/substitution in GJB2 with less invasive sampling procedure in the implication for the clinical application. METHODS: 53 hearing-impaired children and 50 healthy controls were admitted to take part in this study program. DNA samples obtained from buccal swab were used to amplify the exon2 of GJB2, and single run with an automated sequencer was used to identify the one-base deletion. Single-base substitutions were also screened by primer-extension procedure with dye terminators. The presence of both types of mutations was confirmed by direct sequence of the GJB2 exon2. RESULTS: Two of 50 controls (4%) included one-base deletion in GJB2 as heterozygote. 14 of 53 hearing impaired cases (26.4%) contained deletion in GJB2 either as homozygote (five cases) or heterozygote (nine cases) form. Sequencing analysis of whole exon2 of GJB2 identified all these deletions as 235delC. Primer-extension analysis revealed additional mutations with single base substitutions in three cases with compound heterozygote with 235delC. CONCLUSIONS: Rapid screening procedure of GJB2 can be potentially useful for the identification of prelingual deafness.

Better speech performance in cochlear implant patients with GJB2-related deafness.

OBJECTIVE: We applied mutation screening in seven cochlear implant users to identify those persons with GJB2-related deafness to determine whether etiology of deafness was predictive of speech performance after implantation. METHODS: Direct sequence of GJB2 was conducted over seven cochlear implant users with prelingual hearing impairment and their speech, language and cognitive performance was examined. RESULTS: The three persons with GJB2-related deafness had a mean vocabulary of 1243 words compared to a mean vocabulary of 195 words in the four children with GJB2-unrelated deafness, although the number of patients examined here was limited. The developmental quotient (DQ) of cognitive ability also was higher in those children with GJB2-related deafness. CONCLUSIONS: These preliminary results suggest that better speech performance after cochlear implantation may be observed in persons with GJB2-related deafness. In the future, detailed phenotypic studies and mutation screening for non-syndromic hearing loss may play an important role in the preoperative assessment of prelingually-deafened children.