The association between introduction of the micro-axial flow pump Impella in hospitals and in-hospital mortality in patients treated with extracorporeal membrane oxygenation: interrupted time-series analyses.

BACKGROUND: The micro-axial flow pump Impella, a new mechanical circulatory device for cardiogenic shock, is still only available in a limited number of hospitals, due to the facility certification requirements and insufficient evidence of the benefit of introducing Impella in hospitals. This study aimed to evaluate the impact of introducing Impella in hospitals on in-hospital mortality of patients treated with extracorporeal membrane oxygenation (ECMO). METHODS: Using a nationwide Japanese inpatient database, we identified patients who received ECMO during hospitalization between 1 April 2014 and 31 March 2021. A hospital-level propensity score-matched cohort was created matching hospitals that introduced Impella (exposure group) to those that did not introduce Impella (control group). The inclusion period in each hospital was divided into two time periods according to the time of Impella introduction in the exposure group and the corresponding hospital in the control group (before and after exposure). The primary outcome was in-hospital mortality. Uncontrolled and controlled interrupted time-series analyses involved before-after exposure comparison and exposure-control comparison. RESULTS: Out of 34,379 eligible patients, we created a matched cohort of 8351 patients from 86 hospitals with Impella introduction (exposure group) and 7230 patients from 86 hospitals without Impella introduction (control group). In-hospital mortality before and after exposure was 62.5% and 59.3, respectively, in the exposure group; and 66.8% and 63.7%, respectively, in the control group. Uncontrolled interrupted time-series analysis showed no significant level change or trend change in the before-after exposure comparison in both the exposure and the control groups. Controlled interrupted time-series analysis also showed no significant level change (-0.01%; 95% confidence intervals -5.36% to + 5.33%) or trend change (+ 0.10%, -0.30% to + 0.40%) after exposure in the exposure-control comparison. CONCLUSIONS: This nationwide inpatient database study showed no association between Impella introduction in hospitals and in-hospital mortality of patients who underwent ECMO. Because this study confined itself to analze of the impact of the introduction of Impella solely at the hospital level, further detailed studies are warranted to assess its efficacy at the patient level.

Association between Postoperative Adjuvant Vasodilator Therapy and In-Hospital Mortality for Non-Occlusive Mesenteric Ischemia: A Nationwide Observational Study.

BACKGROUND: Although several clinical guidelines recommend vasodilator therapy for non-occlusive mesenteric ischemia (NOMI) and immediate surgery when bowel necrosis is suspected, these recommendations are based on limited evidence. METHODS: In this retrospective nationwide observational study, we used information from the Japanese Diagnosis Procedure Combination inpatient database from July 2010 to March 2018 to identify patients with NOMI who underwent abdominal surgeries on the day of admission. We compared patients who received postoperative vasodilator therapy (vasodilator group) with those who did not (control group). Vasodilator therapy was defined as venous and/or arterial administration of papaverine and/or prostaglandin E1 within 2 days of admission. The primary outcome was in-hospital mortality. Secondary outcomes included the prevalence of additional abdominal surgery performed ≥3 days after admission and short bowel syndrome. RESULTS: We identified 928 eligible patients (149 in the vasodilator group and 779 in the control group). One-to-four propensity score matching yielded 149 and 596 patients for the vasodilator and control groups, respectively. There was no significant difference in in-hospital mortality between the groups (control vs. vasodilator, 27.5% vs. 30.9%; risk difference, 3.4%; 95% confidence interval, -4.9 to 11.6; p=0.42) and no significant difference in the prevalences of abdominal surgery, bowel resection ≥3 days after admission, and short bowel syndrome. CONCLUSIONS: Postoperative vasodilator use was not significantly associated with a reduction in in-hospital mortality or additional abdominal surgery performed ≥3 days after admission in surgically treated NOMI patients.

Development and validation of a novel overhead method for anteroposterior radiographs of fractured rat femurs.

We aimed to establish a new method of obtaining femur anteroposterior radiographs from live rats. We used five adult male Sprague-Dawley rats and created a femoral fracture model with an 8 mm segmental fragment. After the surgery, we obtained two femoral anteroposterior radiographs, a novel overhead method, and a traditional craniocaudal view. We obtained the overhead method three times, craniocaudal view once, and anteroposterior radiograph of the isolated femoral bone after euthanasia. We compared the overhead method and craniocaudal view with an isolated femoral anteroposterior view. We used a two-sample t-test and intraclass correlation coefficient (ICC) to estimate the intra-observer reliability. The overhead method had significantly smaller differences than the craniocaudal view for nail length (1.53 ± 1.26 vs. 11.4 ± 3.45, p < 0.001, ICC 0.96) and neck shaft angle (5.82 ± 3.8 vs. 37.8 ± 5.7, p < 0.001, ICC 0.96). No significant differences existed for intertrochanteric length/femoral head diameter (0.23 ± 0.13 vs. 0.23 ± 0.13, p = 0.96, ICC 0.98) or lateral condyle/medial condyle width (0.15 ± 0.16 vs. 0.13 ± 0.08, p = 0.82, ICC 0.99). A fragment displacement was within 0.11 mm (2.4%). The overhead method was closer to the isolated femoral anteroposterior view and had higher reliability.

Association between pupillary examinations and prognosis in patients with out-of-hospital cardiac arrest who underwent extracorporeal cardiopulmonary resuscitation: a retrospective multicentre cohort study.

BACKGROUND: In some cases of patients with out-of-hospital cardiac arrest (OHCA) who underwent extracorporeal cardiopulmonary resuscitation (ECPR), negative pupillary light reflex (PLR) and mydriasis upon hospital arrival serve as common early indicator of poor prognosis. However, in certain patients with poor prognoses inferred by pupil findings upon hospital arrival, pupillary findings improve before and after the establishment of ECPR. The association between these changes in pupillary findings and prognosis remains unclear. This study aimed to clarify the association of pupillary examinations before and after the establishment of ECPR in patients with OHCA showing poor pupillary findings upon hospital arrival with their outcomes. To this end, we analysed retrospective multicentre registry data involving 36 institutions in Japan, including all adult patients with OHCA who underwent ECPR between January 2013 and December 2018. We selected patients with poor prognosis inferred by pupillary examinations, negative pupillary light reflex (PLR) and pupil mydriasis, upon hospital arrival. The primary outcome was favourable neurological outcome, defined as Cerebral Performance Category 1 or 2 at hospital discharge. Multivariable logistic regression analysis was performed to evaluate the association between favourable neurological outcome and pupillary examination after establishing ECPR. RESULTS: Out of the 2,157 patients enrolled in the SAVE-J II study, 723 were analysed. Among the patients analysed, 74 (10.2%) demonstrated favourable neurological outcome at hospital discharge. Multivariable analysis revealed that a positive PLR at ICU admission (odds ration [OR] = 11.3, 95% confidence intervals [CI] = 5.17-24.7) was significantly associated with favourable neurological outcome. However, normal pupil diameter at ICU admission (OR = 1.10, 95%CI = 0.52-2.32) was not significantly associated with favourable neurological outcome. CONCLUSION: Among the patients with OHCA who underwent ECPR and showed poor pupillary examination findings upon hospital arrival, 10.2% had favourable neurological outcome at hospital discharge. A positive PLR after the establishment of ECPR was significantly associated with favourable neurological outcome.

Factors associated with favourable neurological outcomes following cardiopulmonary resuscitation for out-of-hospital cardiac arrest: A retrospective multi-centre cohort study.

Aim: To investigate the factors associated with favourable neurological outcomes in adult patients undergoing extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest (OHCA). Methods: This retrospective observational study used secondary analysis of the SAVE-J II multicentre registry data from 36 institutions in Japan. Between 2013 and 2018, 2157 patients with OHCA who underwent ECPR were enrolled in SAVE-J II. A total of 1823 patients met the study inclusion criteria. Adult patients (aged ≥ 18 years) with OHCA, who underwent ECPR before admission to the intensive care unit, were included in our secondary analysis. The primary outcome was a favourable neurological outcome at hospital discharge, defined as a Cerebral Performance Category score of 1 or 2. We used a multivariate logistic regression model to examine the association between factors measured at the incident scene or upon hospital arrival and favourable neurological outcomes. Results: Multivariable analysis revealed that shockable rhythm at the scene [odds ratio (OR); 2.11; 95% confidence interval (CI), 1.16-3.95] and upon hospital arrival (OR 2.59; 95% CI 1.60-4.30), bystander CPR (OR 1.63; 95% CI 1.03-1.88), body movement during resuscitation (OR 7.10; 95% CI 1.79-32.90), gasping (OR 4.33; 95% CI 2.57-7.28), pupillary reflex on arrival (OR 2.93; 95% CI 1.73-4.95), and male sex (OR 0.43; 95% CI 0.24-0.75) significantly correlated with neurological outcomes. Conclusions: Shockable rhythm, bystander CPR, body movement during resuscitation, gasping, pupillary reflex, and sex were associated with favourable neurological outcomes in patients with OHCA treated with ECPR.

Etiology-Based Prognosis of Extracorporeal CPR Recipients After Out-of-Hospital Cardiac Arrest: A Retrospective Multicenter Cohort Study.

BACKGROUND: A better understanding of the relative contributions of various factors to patient outcomes is essential for optimal patient selection for extracorporeal CPR (ECPR) therapy for patients with out-of-hospital cardiac arrest (OHCA). However, evidence on the prognostic comparison based on the etiologies of cardiac arrest is limited. RESEARCH QUESTION: What is the etiology-based prognosis of patients undergoing ECPR for OHCA? STUDY DESIGN AND METHODS: This retrospective multicenter registry study involved 36 institutions in Japan and included all adult patients with OHCA who underwent ECPR between January 2013 and December 2018. The primary etiology for OHCA was determined retrospectively from all hospital-based data at each institution. We performed a multivariable logistic regression model to determine the association between etiology of cardiac arrest and two outcomes: favorable neurologic outcome and survival at hospital discharge. RESULTS: We identified 1,781 eligible patients, of whom 1,405 (78.9%) had cardiac arrest because of cardiac causes. Multivariable logistic regression analysis for favorable neurologic outcome showed that accidental hypothermia (adjusted OR, 5.12; 95% CI, 2.98-8.80; P < .001) was associated with a significantly higher rate of favorable neurologic outcome than cardiac causes. Multivariable logistic regression analysis for survival showed that accidental hypothermia (adjusted OR, 5.19; 95% CI, 3.15-8.56; P < .001) had significantly higher rates of survival than cardiac causes. Acute aortic dissection/aneurysm (adjusted OR, 0.07; 95% CI, 0.02-0.28; P < .001) and primary cerebral disorders (adjusted OR, 0.12; 95% CI, 0.03-0.50; P = .004) had significantly lower rates of survival than cardiac causes. INTERPRETATION: In this retrospective multicenter cohort study, although most patients with OHCA underwent ECPR for cardiac causes, accidental hypothermia was associated with favorable neurologic outcome and survival; in contrast, acute aortic dissection/aneurysm and primary cerebral disorders were associated with nonsurvival compared with cardiac causes.

Association between neuromuscular blocking agent use and outcomes among out-of-hospital cardiac arrest patients treated with extracorporeal cardiopulmonary resuscitation and target temperature management: A secondary analysis of the SAVE-J II study.

Background: Neuromuscular blocking agents are used to control shivering in cardiac arrest patients treated with target temperature management. However, their effect on outcomes in patients treated with extracorporeal cardiopulmonary resuscitation is unclear. Methods: This study was a secondary analysis of the SAVE-J II study, a retrospective multicenter study of 2175 out-of-hospital cardiac arrest patients treated with extracorporeal cardiopulmonary resuscitation in Japan. We classified patients into those who received neuromuscular blocking agents and those who did not and compared in-hospital mortality and incidence rates of favorable neurological outcome and in-hospital pneumonia between the groups using multivariable regression models and stabilized inverse probability weighting with propensity scores. Results: Six hundred sixty patients from the SAVE-J II registry were analyzed. Neuromuscular blocking agents were used in 451 patients (68.3%). After adjusting for potential confounders, neuromuscular blocking agents use was not significantly associated with in-hospital mortality (aHR 0.88; 95% CI, 0.67-1.14), favorable neurological outcome (aOR 0.85; 95% CI, 0.60-1.11), or pneumonia (aOR 1.52; 95% CI, 0.85-2.71). The results for in-hospital mortality (aHR 0.89; 95% CI, 0.64-1.25), favorable neurological outcome (aOR 0.94; 95% CI, 0.59-1.48) and pneumonia (aOR 1.59; 95% CI, 0.74-3.41) were similar after weighting was performed. Conclusions: Although data on the rationale for using neuromuscular blocking agents were unavailable, their use was not significantly associated with outcomes in out-of-hospital cardiac arrest patients treated with extracorporeal cardiopulmonary resuscitation and targeted temperature management. Neuromuscular blocking agents should be used based on individual clinical indications.

Delayed stomach necrosis in a patient with injured celiac artery branches after penetrating abdominal trauma.

Injuries of the celiac artery and its branches are rare, but potentially lethal. Ligation of these arteries is performed to control significant hemorrhage. However, few reports have described the adverse effects of ligating these arteries. A 69-year-old woman with a self-inflicted stab wound was brought to our hospital. Her blood pressure could not be measured, therefore aortic cross-clamping was performed, and epinephrine was administered for resuscitation, an emergency laparotomy was performed, and the roots of splenic artery and common hepatic artery were ligated. The left gastric artery which was anomalous and arose directly from the aorta, was also injured and had to be ligated. Norepinephrine was required after the surgery. Enhanced computed tomography performed on hospital day 4 revealed a disrupted celiac artery. The patient developed gastric necrosis on hospital day 23 and, hence, underwent total gastrectomy was performed. The possibility of delayed stomach necrosis should be considered during the postoperative management of patients who undergo ligation of all of the celiac artery branches and experience global hypoperfusion after the surgery.

Trends in Mechanical Circulatory Support Use and Outcomes of Patients With Cardiogenic Shock in Japan, 2010 to 2020 (from a Nationwide Inpatient Database Study).

Little is known about the impact of the downgrade of guideline recommendations for intra-aortic balloon pump (IABP) use and the approval of the Impella in Japan, where IABPs have been predominantly used. This study aimed to describe the annual trends in the mechanical circulatory support (MCS) use and outcomes in patients with cardiogenic shock (CS) requiring MCS. Using the Japanese Diagnosis Procedure Combination database from July 2010 to March 2021, we identified inpatients with CS requiring MCS. The patients were stratified into 3 groups: (1) IABP alone, (2) Impella alone, and (3) extracorporeal membrane oxygenation (ECMO), regardless of IABP or Impella use. The patient characteristics and outcomes were reported by the fiscal year. Of the 160,559 eligible patients, 117,599 (73.2%) used IABP alone, 1,465 (0.9%) Impella alone, and 41,495 (25.8%) ECMO. The prevalence of the use of an IABP alone significantly decreased from 80.5% in 2010 to 65.3% in 2020 (p for trend <0.001), whereas the prevalence of the use of an Impella alone significantly increased from 0.0% to 5.0% and ECMO from 19.5% to 29.6% (p for trend <0.001 for both). In-hospital mortality significantly increased from 29.3% in 2010 to 32.6% in 2020 in the overall patients with CS requiring MCS but significantly decreased in those requiring ECMO from 73.7% to 64.1% (p for trend <0.001 for both). In conclusion, there were significant annual changes in the patterns of MCS use and clinical outcomes in patients with CS requiring MCS.

Efficacy and safety of anamorelin in patients with cancer cachexia: Post-hoc subgroup analyses of a placebo-controlled study.

BACKGROUND: Cachexia, a disorder associated with anorexia, inflammation, and muscle wasting, is frequent in cancer patients. We performed post-hoc analyses of the ONO-7643-04 study to investigate the efficacy and safety of anamorelin in subgroups of Japanese patients with non-small cell lung cancer (NSCLC). METHODS: The patients were divided into subgroups by baseline characteristics, including sex, age, body mass index, prior weight loss, performance status (PS), concomitant anticancer therapy, and number of previous chemotherapy regimens. The changes from baseline through to 12 weeks for lean body mass (LBM), body weight, and appetite were calculated. Appetite was evaluated using the quality of life questionnaire for cancer patients treated with anticancer drugs (QOL-ACD) item 8 score. Responder rates were defined as the maintenance/improvement of LBM (≥0 kg), body weight (≥0 kg), or QOL-ACD item 8 score (≥0) from baseline to all evaluation time points. Safety was evaluated in patients subgrouped by age and PS. RESULTS: Anamorelin resulted in greater improvements versus placebo in LBM, body weight, and appetite in most subgroups. Anamorelin was also associated with greater LBM, body weight, and appetite responder rates than placebo in nearly all subgroups. Among anamorelin-treated patients, adverse drug reactions (ADRs) tended to be more frequent with increasing age (<65 years, 19.2%; ≥65 to <75 years, 45.9%; ≥75 years, 60.0%) and PS score (PS 0-1, 38.4%; PS 2, 60.0%). The frequency of serious ADRs was 2.7% and 0% in the PS 0-1 and PS 2 subgroups, respectively. CONCLUSION: This study of NSCLC patients with cancer cachexia revealed consistent improvements in LBM, body weight, and appetite across most subgroups of anamorelin-treated patients. This study also demonstrated the tolerability of anamorelin regardless of age and PS, with a low incidence of serious ADRs in each subgroup.

Two Cases of Bronchial Artery Racemose Hemangioma Successfully Treated with Bronchial Artery Embolization.

Rupture of a racemose hemangioma causing dilatation and tortuosity of the bronchial artery can result in massive bleeding and respiratory failure. Bronchial artery embolization (BAE) can treat this life-threatening condition, as we show in two cases. The first case was of an 89-year-old female complaining of sudden-onset chest and back pain. Bronchial artery angiography demonstrated a racemose hemangioma with a 2 cm aneurysm. The second case was of a 50-year-old male with hemoptysis and dyspnea, eventually requiring intubation. Bronchial arteriography showed a racemose hemangioma and a bronchial artery-pulmonary arterial fistula. BAE was successfully performed in both cases, with no recurrent hemorrhage. Therapeutic interventions in bronchial artery racemose hemangiomas include lobectomy or segmentectomy, bronchial arterial ligation, and BAE. BAE should be considered as first-line therapy for bleeding racemose hemangiomas of the bronchial artery because of its low risk of adverse effects on respiratory status, minimal invasiveness, and faster patient recovery.

Extracorporeal cardiopulmonary resuscitation in adult patients with out-of-hospital cardiac arrest: a retrospective large cohort multicenter study in Japan.

BACKGROUND: The prevalence of extracorporeal cardiopulmonary resuscitation (ECPR) in patients with out-of-hospital cardiac arrest (OHCA) has been increasing rapidly worldwide. However, guidelines or clinical studies do not provide sufficient data on ECPR practice. The aim of this study was to provide real-world data on ECPR for patients with OHCA, including details of complications. METHODS: We did a retrospective database analysis of observational multicenter cohort study in Japan. Adult patients with OHCA of presumed cardiac etiology who received ECPR between 2013 and 2018 were included. The primary outcome was favorable neurological outcome at hospital discharge, defined as a cerebral performance category of 1 or 2. RESULTS: A total of 1644 patients with OHCA were included in this study. The patient age was 18-93 years (median: 60 years). Shockable rhythm in the initial cardiac rhythm at the scene was 69.4%. The median estimated low flow time was 55 min (interquartile range: 45-66 min). Favorable neurological outcome at hospital discharge was observed in 14.1% of patients, and the rate of survival to hospital discharge was 27.2%. The proportions of favorable neurological outcome at hospital discharge in terms of shockable rhythm, pulseless electrical activity, and asystole were 16.7%, 9.2%, and 3.9%, respectively. Complications were observed during ECPR in 32.7% of patients, and the most common complication was bleeding, with the rates of cannulation site bleeding and other types of hemorrhage at 16.4% and 8.5%, respectively. CONCLUSIONS: In this large cohort, data on the ECPR of 1644 patients with OHCA show that the proportion of favorable neurological outcomes at hospital discharge was 14.1%, survival rate at hospital discharge was 27.2%, and complications were observed during ECPR in 32.7%.

A multicenter, open-label, single-arm study of anamorelin (ONO-7643) in patients with cancer cachexia and low body mass index.

BACKGROUND: Cancer cachexia is a syndrome characterized by anorexia and decreased body weight. This study evaluated the efficacy and safety of anamorelin, an orally active, selective ghrelin receptor agonist, in patients with cancer cachexia and a low body mass index (BMI). METHODS: This multicenter, open-label, single-arm study enrolled Japanese patients with non-small cell lung cancer or gastrointestinal cancer with cancer cachexia (BMI < 20 kg/m2 , involuntary weight loss > 2% in the last 6 months, and anorexia). Patients were administered 100 mg of anamorelin once daily for up to 24 weeks. The primary end point was a composite clinical response (CCR) at 9 weeks, which was defined as an increase in body weight of ≥5% from the baseline, an increase of ≥2 points in the score of the 5-item Anorexia Symptom Scale of the Functional Assessment of Anorexia/Cachexia Therapy, and being alive. RESULTS: One hundred two patients were eligible and enrolled. The means and standard deviations for age and BMI were 71.0 ± 8.2 years and 17.47 ± 1.48 kg/m2 , respectively. The CCR rate at 9 weeks was 25.9% (95% confidence interval [CI], 18.3%-35.3%), which met the primary end point with a lower 95% CI exceeding the prespecified minimum of 8%. Improvements in body weight and anorexia were durable and were accompanied by improvements in patients' global impression of change for appetite/eating-related symptoms and overall condition. Adverse drug reactions occurred in 37 of 101 treated patients (36.6%), with the most common being glycosylated hemoglobin increases, constipation, and peripheral edema. CONCLUSIONS: Anamorelin improved body weight and anorexia-related symptoms in patients with cancer cachexia and a low BMI with durable efficacy and favorable safety and tolerability. LAY SUMMARY: Anamorelin is a drug that stimulates appetite and promotes weight gain. This clinical trial was aimed at determining its efficacy and safety in Japanese cancer patients with a low body mass index and cachexia, a syndrome associated with anorexia and weight loss. Anamorelin was found to improve body weight and anorexia-related symptoms in these patients, and these effects were durable for up to 24 weeks. Moreover, anamorelin was generally well tolerated. These findings suggest that anamorelin is a valuable treatment option for patients with cancer cachexia and a low body mass index.

Successful multidisciplinary management of vascular Ehlers-Danlos syndrome.

Vascular Ehlers-Danlos syndrome is a rare connective tissue disease with a high risk of severe complications. Because of these complications, the median life expectancy for patients with vascular Ehlers-Danlos syndrome is estimated at 48 years. However, the optimal management of these complications remains unclear. A 25-year-old man with abdominal pain was transported to our hospital by ambulance. He had undergone Hartmann's operation at 22 years of age for a first-time colonic perforation. At that time, a genetic test revealed germline variants in COL3A1, which encodes type III procollagen; therefore, the patient was diagnosed with vascular Ehlers-Danlos syndrome. When the patient presented to our hospital, we suspected another colonic perforation and thus performed an emergency operation. Open abdominal management, transcatheter arterial embolization, and negative-pressure wound therapy were performed as life-saving measures. Notably, these procedures should initially be avoided in patients with vascular Ehlers-Danlos syndrome because of tissue fragility. Open abdominal management, transcatheter arterial embolization, and negative-pressure wound therapy may be useful for patients with vascular Ehlers-Danlos syndrome who develop panperitonitis and massive intra-abdominal bleeding.

A nationwide web-based survey of factors associated with depressive symptoms among Japanese workers.

BACKGROUND: Precarious employment has affected mental health, and limited data are available on the association of low stress tolerance with depressive symptoms among Japanese workers. AIMS: This study aimed to examine the relationship between stress tolerance and depressive symptoms among Japanese workers, including company employees, civil servants and self-employed persons in various industries. METHODS: We conducted a nationwide cross-sectional study. From March 26 to April 6, 2020, we performed a web-based survey of Japanese workers. The questionnaire included questions on socioeconomic factors, the SOC scale that assesses stress tolerance, the CES-D, and the EQ-5D-5L. Multivariate regression analyses were performed to determine the factors associated with depressive symptoms. RESULTS: We included 3,001 participants in the analysis. A high SOC score, adequate sleeping time and frequency of exercise were associated with higher depressive symptoms. Employment status and long working hours were not associated with depressive symptoms. Younger workers had lower SOC scores than older workers. An inverse correlation between the SOC score and CES-D score was found among Japanese workers. CONCLUSIONS: Improving stress tolerance among younger workers is needed to prevent worsening mental health regardless of employment status for Japanese workers.

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.

Variability of extracorporeal cardiopulmonary resuscitation practice in patients with out-of-hospital cardiac arrest from the emergency department to intensive care unit in Japan.

AIM: A lack of known guidelines for the provision of extracorporeal cardiopulmonary resuscitation (ECPR) to patients with out-of-hospital cardiac arrest (OHCA) has led to variability in practice between hospitals even in the same country. Because variability in ECPR practice has not been completely examined, we aimed to describe the variability in ECPR practice in patients with OHCA from the emergency department (ED) to the intensive care units (ICU). METHODS: An anonymous online questionnaire to examine variability in ECPR practice was completed in January 2020 by 36 medical institutions who participated in the SAVE-J II study. Institutional demographics, inclusion and exclusion criteria, initial resuscitation management, extracorporeal membrane oxygenation (ECMO) initiation, initial ECMO management, intra-aortic balloon pumping/endotracheal intubation/management during coronary angiography, and computed tomography criteria were recorded. RESULTS: We received responses from all 36 institutions. Four institutions (11.1%) had a hybrid emergency room. Cardiovascular surgery was always involved throughout the entire ECMO process in only 14.7% of institutions; 60% of institutions had formal inclusion criteria and 50% had formal exclusion criteria. In two-thirds of institutions, emergency physicians carried out cannulation. Catheterization room was the leading location of cannulation (48.6%) followed by ED (31.4%). The presence of formal exclusion criteria significantly increased with increasing ECPR volume (P for trend <0.001). Intra-aortic balloon pumping was routinely initiated in only 25% of institutions. Computed tomography was routinely carried out before coronary angiography in 25% of institutions. CONCLUSIONS: We described the variability in ECPR practice in patients with OHCA from the ED to the ICU.

Psychological impact of the state of emergency over COVID-19 for non-permanent workers: a Nationwide follow-up study in Japan.

BACKGROUND: The outbreak of COVID-19 has caused mental health problems and increased unemployment due to the economic recession. This survey aimed to assess the psychological impact of the state of emergency. We estimated changes in mental health, quality of life, and unemployment experience for general workers during the first COVID-19 outbreak in Japan. METHODS: We conducted a nationwide follow-up study. During the periods of March 26 to April 6, 2020 and June 26 to July 2, 2020, we used the internet to survey general workers aged 15 to 59 years in Japan. The questionnaire items covered employment status and socioeconomic factors, and we used the Center for Epidemiologic Studies Depression Scale (CES-D) and EQ-5D-5L to assess depression and health-related quality of life (HR-QOL), respectively. The differences in outcomes of permanent and non-permanent workers were analyzed using propensity score analysis. A multiple linear regression analysis was performed to examine the relationship between unemployment and CES-D scores. RESULTS: We included 2351 subjects in the analysis. Changes in both CES-D scores and utility were not significantly different between the two groups. However, a significant difference was found regarding the rate of unemployment, which was associated with higher CES-D scores. CONCLUSIONS: The present study demonstrated that the mental health of non-permanent workers was not negatively affected following the state of emergency due to COVID-19 in Japan. Unemployment is an important factor that influences the mental health of general workers.

Intermittent versus continuous neuromuscular blockade during target temperature management after cardiac arrest: A nationwide observational study.

PURPOSE: Whether intermittent or continuous neuromuscular-blocking agents (NMBAs) would be appropriate during target temperature management (TTM) after cardiac arrest remains unclear. MATERIALS AND METHODS: In this retrospective cohort study, we utilized the Japanese Diagnosis Procedure Combination inpatient database from July 2010 to March 2018 and identified patients who received NMBAs during TTM after cardiac arrest on the day of admission. We compared the in-hospital mortality between the propensity-score-matched intermittent and continuous NMBA groups. RESULTS: We identified 5584 eligible patients; 1488 received intermittent NMBAs and 4096 received continuous NMBAs. After propensity score matching, there was no significant difference in the in-hospital mortality between the intermittent and continuous NMBA groups (32.9% vs. 33.1%; odds ratio, 0.98; 95% confidence interval, 0.82-1.18). In subgroup analyses, in-hospital mortality of the continuous NMBA group was significantly higher than that of the intermittent NMBA group in patients aged ≥65 years (p for interaction = 0.021). CONCLUSIONS: This large retrospective study did not suggest that intermittent NMBAs may be inferior to continuous NMBAs in terms of mortality reduction in the overall population receiving TTM for cardiac arrest. However, continuous NMBAs may be inferior to intermittent NMBAs for reducing mortality in elderly patients.

Portal Venous Gas in Adults: Clinical Significance, Management, and Outcomes of 25 Consecutive Patients.

BACKGROUND: Portal venous gas (PVG) is a rare finding and has a grave prognosis. The most common and critical underlying pathology of PVG is bowel necrosis. However, bowel necrosis is sometimes difficult to accurately diagnose. We retrospectively analyzed data from patients that contributed to the decision to perform emergency surgery and bowel resection. METHODS: Between 2009 and 2019, 25 consecutive adult patients with PVG were identified retrospectively and divided into the Operation and Non-operation groups. The Operation group was further subdivided into the Bowel resection and Non-resection groups. Clinical, laboratory, and radiographic variables were analyzed. RESULTS: Conservative management was successful for 32% (8/25) of patients (Non-operation group: mortality 0%); 68% (17/25) were treated surgically (Operation group: mortality 35.3%). In the Operation group, 52.9% (9/17) underwent bowel resection (Bowel resection group: mortality 55.6%); however, bowel resection was unnecessary in 47.1% (8/17) of cases (Non-resection group: mortality 12.5%). Univariate analysis revealed significant differences between the Operation and Non-operation groups in GCS, APACHE II, abdominal distention, CRP, lactate, and CT findings of bowel dilatation, pneumatosis intestinalis, and attenuation of contrast effects of the bowel wall. However, with the exception of GCS, there was no significant difference between the Bowel resection and Non-resection groups. CONCLUSIONS: Analysis of clinical, laboratory, and radiographic variables can inform decisions on conservative management. However, 47.1% of the present patients who underwent surgery for suspected bowel necrosis did not require bowel resection, suggesting that this approach alone may not be sufficient to avoid non-therapeutic laparotomy. A new approach should be developed to improve this situation.