Characteristics and outcomes of out-of-hospital cardiac arrest in a hilly area: Utstein Registry data from the Nagasaki Medical Region, Japan.

Aim: To analyze characteristics and investigate prognostic indicators of out-of-hospital cardiac arrest (OHCA) in a hilly area in Japan. Methods: A retrospective population-based study was conducted using the Utstein Registry for 4280 OHCA patients in the Nagasaki Medical Region (NMR) registered over the 10-year period from 2011 to 2020. The main outcome measure was a favorable cerebral performance category (CPC 1-2). Sites at which OHCA occurred were classified into "sloped places (SPs)" (not easily accessible by emergency medical services [EMS] personnel due to slopes) and "accessible places (APs)" (EMS personnel could park an ambulance close to the site). The characteristics and prognosis based on CPC were compared between SPs and APs, and multivariable analysis was performed. Results: No significant improvement in prognosis occurred in the NMR from 2011 to 2020. Prognosis in SPs was significantly worse than that in APs. However, multivariable analysis did not identify SP as a prognostic indicator. The following factors were associated with survival and CPC 1-2: age group, witness status, first documented rhythm, bystander-initiated cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) use, use of mechanical CPR (m-CPR) device or esophageal obturator airway (EOA), and year. Both m-CPR and EOA use were associated with a poor prognosis. Conclusion: In a hilly area, OHCA patients in SPs had a worse prognosis than those in APs, but SPs was not significantly associated with prognosis by multivariable analysis. Interventions to increase bystander-initiated CPR and AED use could potentially improve outcomes of OHCA in the NMR.

Attitude of Emergency Medical Technicians Toward Electrocardiogram　- Needs of Electrocardiogram Training Courses and Other Learning Opportunities.

BACKGROUND: Early intervention in prehospital settings is important for treating patients with acute coronary syndrome (ACS). Emergency medical technicians (EMTs) are the essential first responders who treat these patients, and their current attitudes towards electrocardiograms (ECGs) have not been identified. This study investigated the awareness of EMTs of ECGs to shorten hospital arrival time, improving patient prognosis.Methods and Results: An anonymous questionnaire survey, with 27 statements about ECG and ACS response, was administered to 395 EMTs. The statements were related to interest, motivation, learning status, confidence, and norms pertaining to ECGs, a sense of perceived behavioral control, and training courses. The primary outcome was the perception of EMTs that their interpretation of an ECG affected patient prognosis (Statement [S] 1). Participants assigned scores for each statement using a scale ranging from 1 (strongly disagree) to 10 (strongly agree). The mean score for S1 was 7.09. Mean scores for statements regarding confidence and learning status were 3.96 and 3.53, respectively. The participants had a positive impression of training courses (score >5.5). CONCLUSIONS: The EMTs experience was that their interpretation of an ECG could affect the prognosis of patients with ACS. Conversely, they lacked confidence reading ECGs, but were willing to attend ECG training courses. Therefore, efficient training programs need to be established to achieve a better prognosis for ACS patients.

Exotic (non-native) snakebite envenomation in Japan: A review of the literature between 2000 and 2022.

A limited number of studies have investigated the clinical characteristics of snakebite envenomation by exotic (non-native) snakes in Japan. This study reviewed the literature to determine the status and risk of bites by exotic pet snakes in Japan. We reviewed reports of snakebite due to exotic snakes in Japan published between 2000 and 2022, excluding reports of bites by snakes native to Japan, such as Gloydius blomhoffii, Rhabdophis tigrinus, and Protobothrops flavoviridis. During the study period, 11 exotic snakebites were recorded, involving 11 species. The majority of those bitten (10/11 cases) were male, all cases were hand injuries, and there were no fatalities. The snakes responsible belonged to the Colubridae (4/11 cases), Viperidae (4/11 cases), and Elapidae (3/11 cases) families. Cases of envenomation by G. brevicaudus, Bungarus candidus, and Dendroaspis angusticeps were of particular interest. Ten of the eleven patients developed local cytotoxic signs, and three developed "compartment syndrome," in which the surgeons performed decompressive incisions. Two bites from elapid snakes and one from a viperid snake resulted in respiratory failure. Antivenom was given in two cases. Complications were observed, such as acute kidney injury, rhabdomyolysis, coagulopathy, and residual dysfunction of the affected finger. Emergency rooms should be prepared to manage patients who have been bitten by exotic snakes, even though the number of reported cases is not high in Japan. Initial stabilization of patients is crucial, before a definitive diagnosis is made, as with native snakebite envenomation. Finger bites are reported in most cases, which may result in functional impairment of the fingers. In order to collect more comprehensive patient data in Japan, a reporting system for all snakebite envenomations should be considered.

Balance of the prooxidant and antioxidant system is associated with mortality in critically ill patients.

It is well known that oxidative stress causes certain diseases and organ damage. However, roles of oxidative stress in the acute phase of critical patients remain to be elucidated. This study aimed to investigate the balance of oxidative and antioxidative system and to clarify the association between oxidative stress and mortality in critically ill patients. This cohort study enrolled 247 patients transported to our emergency department by ambulance. Blood was drawn on hospital arrival, and serum derivatives of reactive oxidant metabolites (dROMs, oxidative index) and biological antioxidant potential (BAP, antioxidative index) were measured. Modified ratio (MR) is also calculated as BAP/dROMs/7.51. There were 197 survivors and 50 non-survivors. In the non-survivors, dROMs were significantly lower (274 vs 311, p<0.01), BAP was significantly higher (2,853 vs 2,138, p<0.01), and MR was significantly higher (1.51 vs 0.92, p<0.01) compared to those in the survivors. The AUC of MR was similar to that for the APACHE II score. Contrary to our expectations, higher BAP and lower dROMs were observed on admission in non-survivors. This may suggest that the antioxidative system is more dominant in the acute phase of severe insults and that the balance toward a higher antioxidative system is associated with mortality.

Current situation survey for establishing personally acceptable radiation dose limits for nuclear disaster responders.

When responding to disasters, emergency preparedness is essential to ensure that disaster activities are performed smoothly, safely and efficiently. Investigations on the Fukushima accident revealed that lack of preparedness, poor communication and unsuitable emergency measures contributed to an inadequate emergency response to the nuclear disaster. In this study, we conducted a questionnaire survey on the establishment of a personal radiation exposure dose among Disaster Medical Assistance Team (DMAT) members in Japan who might be involved in the initial response to a nuclear disaster. Establishing personal exposure doses for personnel can encourage emergency preparedness and inform decisions on appropriate role assignments during nuclear response activities. Valid responses were obtained from 178 participants, and the response distribution was as follows: 'Already have own acceptable dose standard,' 16 (9%); 'Follow own institution's standard (and know its value),' 30 (17%); 'Follow own institution's standard (but do not know its value),' 59 (33%); 'Haven't decided,' 63 (35%) and 'Don't understand question meaning,' 10 (6%). We also assessed intention to engage in nuclear disaster activities among respondents via engagement intent scores (EIS) and found that participants who had established personal exposure standards had significantly higher EIS scores than those who had not decided or who did not understand the question. Thus, educating potential nuclear disaster responders on personal exposure doses may contribute to a higher intention to engage in emergency responses and improve preparedness and response efficiency.

Increasing Disaster Medical Assistance Teams' Intent to Engage with Specific Hazards.

To ensure human resource availability for a smooth response during various types of disasters, there is a need to improve the intent of those involved in responding to each hazard type. However, Disaster Medical Assistance Team personnel's intent to engage with specific hazards has yet to be clarified. This study therefore aimed to clarify the factors affecting Disaster Medical Assistance Team members' (n = 178) intent to engage with each type of hazard through an anonymous web questionnaire survey containing 20 questions. Our results show that the intent to engage in disaster response activities was significantly lower for chemical (50), biological (47), radiological/nuclear (58), and explosive (52) incidents compared with natural (82) and man-made hazards (82) (p < 0.01). Multiple regression analysis showed that incentives were the most common factor affecting responders' intent to engage with all hazard types, followed by self-confidence. Thus, creating a system that provides generous incentives could effectively improve disaster responders' intent to engage with specific hazards. Another approach could be education and training to increase disaster responders' confidence. We believe that the successful implementation of these measures would improve the intent of responders to engage with hazards and promote the recruitment of sufficient human resources.

Survey about Intention to Engage in Specific Disaster Activities among Disaster Medical Assistance Team Members.

INTRODUCTION: Different disaster activities should be performed smoothly. In relation to this, human resources for disaster activities must be secured. To achieve a stable supply of human resources, it is essential to improve the intentions of individuals responding to each type of disaster. However, the current intention of Disaster Medical Assistance Team (DMAT) members has not yet been assessed. STUDY OBJECTIVE: To facilitate a smooth disaster response, this survey aimed to assess the intention to engage in each type of disaster activity among DMAT members. METHODS: An anonymous web questionnaire survey was conducted. Japanese DMAT members in the nuclear disaster-affected area (Group A; n = 79) and the non-affected area (Group N; n = 99) were included in the analysis. The outcome was the answer to the following question: "Will you actively engage in activities during natural, human-made, and chemical (C), biological (B), radiological/nuclear (R/N), and explosive (E) (CBRNE) disasters?" Then, questionnaire responses were compared according to disaster type. RESULTS: The intention to engage in C (50), B (47), R/N (58), and E (52) disasters was significantly lower than that in natural (82) and human-made (82) disasters (P <.001). The intention to engage in CBRNE disasters among younger participants (age ≤39 years) was significantly higher in Group A than in Group N. By contrast, the intention to engage in R/N disasters alone among older participants (age ≥40 years) was higher in Group A than in Group N. However, there was no difference between the two groups in terms of intention to engage in C, B, and E disasters. Moreover, the intention to engage in all disasters between younger and older participants in Group A did not differ. In Group N, older participants had a significantly higher intention to engage in B and R/N disasters. CONCLUSION: Experience with a specific type of calamity at a young age may improve intention to engage in not only disasters encountered, but also other types. In addition, the intention to engage in CBRNE disasters improved with age in the non-experienced population. To respond smoothly to specific disasters in the future, measures must be taken to improve the intention to engage in CBRNE disasters among DMAT members.

Impact of plasma 5-hydroxyindoleacetic acid, a serotonin metabolite, on clinical outcome in septic shock, and its effect on vascular permeability.

Septic shock is characterized by dysregulated vascular permeability. We hypothesized that the vascular permeability of endothelial cells (ECs) would be regulated by serotonin via serotonin-Rho-associated kinase (ROCK) signaling. We aimed to determine the impact of 5-hydroxyindoleacetic acid (5-HIAA) on septic shock as a novel biomarker. Plasma 5-HIAA levels and disease severity indices were obtained from 47 patients with sepsis. The association between 5-HIAA levels and severity indices was analyzed. Permeability upon serotonin stimulation was determined using human pulmonary microvascular ECs. 5-HIAA were significantly higher in septic shock patients than in patients without shock or healthy controls (p = 0.004). These elevated levels were correlated with severity indexes (SOFA score [p < 0.001], APACHE II [p < 0.001], and PaO2:FiO2 [p = 0.02]), and longitudinally associated with worse clinical outcomes (mechanical ventilation duration [p = 0.009] and ICU duration [p = 0.01]). In the experiment, serotonin increased the permeability of ECs, which was inhibited by the ROCK inhibitor (p < 0.001). Serotonin increases vascular permeability of ECs via ROCK signaling. This suggests a novel mechanism by which serotonin disrupts endothelial barriers via ROCK signaling and causes the pathogenesis of septic shock with a vascular leak. Serotonin serves as a novel biomarker of vascular permeability.

The expression of repulsive guidance molecule a after traumatic brain injury: Time-course changes in gene expression in a murine model of controlled cortical impact.

INTRODUCTION: Repulsive guidance molecule a (RGMa) is a key protein that negatively regulates neuronal regeneration as its inhibition enhances axonal growth and promotes functional recovery in animal models of spinal cord injury. However, the role of RGMa in traumatic brain injury (TBI) remains elusive. This study aimed to clarify TBI-responsive RGMa expression in a murine model. METHODS: Adult male C57BL/6J mice were subjected to controlled cortical impact. Brains were extracted 6 hours and 1, 3, 7, 14 and 21 days after injury (n = 6 in each group). Changes in the messenger RNA (mRNA) expression of RGMa and its receptor, neogenin, were evaluated by quantitative polymerase chain reaction in the damaged area of the cortex and contralateral cortex, along with expression measurement of inflammation-related molecules. Neurological deficit was also assessed by the cylinder test. RESULTS: Neurological score was consistently lower in the TBI group compared to the sham group throughout the experimental period. The mRNA expressions of representative inflammatory cytokine TNF-α and chemokine receptor CCR2 were remarkably increased in the injured cortex on day 1 and gradually decreased over time, although remaining at higher values at least until day 14. The mRNA expressions of RGMa and neogenin were significantly suppressed in the damaged cortex until day 3. Interestingly, RGMa expression was suppressed most on day 1 and recovered over time. CONCLUSION: In the acute phase of TBI, gene expression of inflammatory cytokines significantly increased, and gene expressions of RGMa and neogenin significantly decreased in the inflammatory milieu of the damaged area. Despite the subsequent remission of inflammation, RGMa gene expression recovered to the normal level 1 week after TBI. Intrinsic regenerative response to acute brain injury might be hampered by the following recovery of RGMa expression, hinting at the possibility of functional RGMa inhibition as a new, effective maneuver against TBI.

How to Safely Prevent Venous Thromboembolism in Severe Trauma Patients.

Venous thromboembolism (VTE) is a life-threatening complication after trauma. Several studies have reported VTE prophylaxis using low-molecular-weight heparin; however, there is no consensus for prophylaxis after trauma. This study aimed to assess the efficacy and safety of our new anticoagulation therapy protocol using unfractionated heparin (UFH) plus intermittent pneumatic compression (IPC) to prevent post-traumatic VTE in high-risk trauma patients.This study enrolled 70 trauma patients who were admitted to the emergency medical center of Nagasaki University Hospital and had Risk Assessment Profile (RAP) scores ≥ 5. After stopping bleeding at the trauma site, all patients received intravenous UFH (10,000 U/day) plus IPC, which was continued for 14 days or until the patients could walk. On days 7 and 14, all patients underwent lower extremity sonography for deep-vein thrombosis screening. VTE incidences between patients with the above intervention and historical controls with IPC alone were compared.No significant differences in age, sex, and the RAP score were observed between the 105 controls and intervention patients. VTE occurrence was fewer in patients with the intervention (14.3%) than in the controls (28.6%; P = 0.029). No hemorrhagic complications occurred after UFH administration. Multivariable logistic analysis revealed a significant association between the intervention and low incidence of VTE (odds ratio: 0.390; 95% confidence interval: 0.163-0.913; P = 0.030).Routine UFH administration with IPC may prevent post-traumatic VTE without adverse events.

Impact of fecal short-chain fatty acids on prognosis in critically ill patients.

AIM: This study aimed to evaluate the relationship between fecal organic acids and mortality in critically ill patients. METHODS: This retrospective study included 128 patients who fulfilled the criteria of systemic inflammatory response syndrome and had a serum C-reactive protein level of greater than 10 mg/dL. Patients were treated in the intensive care unit for more than 2 days. Patients were divided into two groups: survivors and non-survivors. We measured and compared eight kinds of fecal organic acids between the two groups. We focused on the minimum and maximum value of each fecal organic acid and evaluated prognostic factors by using classification and regression tree (CART) and multivariate logistic regression analyses. RESULTS: We included 90 patients as survivors and 38 as non-survivors. The CART analysis revealed that the dominant factors for mortality were the minimum values of propionate and acetate and the maximum values of lactate and formic acid. In the evaluation of the minimum values of fecal organic acids, propionate was significantly associated with increased mortality (odds ratio, 0.11 [95% confidence interval, 0.024-0.51]; P = 0.005), acetate (0.047 [0.005-0.49]; P = 0.01), and age (1.048 [1.015-1.083]; P = 0.004). In the evaluation of the maximum values, lactate was significantly associated with increased mortality (5.21 [2.024-13.42], P = 0.001) and age (1.050 [1.017-1.084]; P = 0.003). CONCLUSION: An altered balance of fecal organic acids was significantly associated with mortality in critically ill patients.

Serial change of neutrophil extracellular traps in tracheal aspirate of patients with acute respiratory distress syndrome: report of three cases.

BACKGROUND: Neutrophil extracellular traps (NETs) are fibrous structures released from activated neutrophils. NET formation has been reported to be associated with acute respiratory distress syndrome (ARDS). However, there are no reports dealing with serial changes of NET formation in tracheal aspirate of ARDS patients. CASE PRESENTATION: We report three cases of ARDS. Case 1 is a 69-year-old man with necrotizing fasciitis of the buttocks, case 2 is a 49-year-old woman with extensive burns (80% of total body surface), and case 3 is a 73-year-old woman with severe bacterial pneumonia. We found abundant expression of citrullinated histone H3 (Cit-H3) and the formation of NETs at the onset of ARDS in all cases. The amounts of Cit-H3 and NETs decreased with the amelioration of respiratory failure in cases 1 and 2. In case 2, the amounts of Cit-H3 and NETs increased with aggravation of infection and respiratory status. In case 3, the abundant expression of Cit-H3 and NETs persisted; the patient did not recover from ARDS and eventually died. Cit-H3 and NETs were found in tracheal aspirates even if the patients had no direct injury to the lung as in cases 1 and 2. CONCLUSIONS: In these three cases, the formation of NETs was observed in tracheal aspirate of patients with ARDS by either direct or indirect insults to the lung. The amount of NET formation changed dynamically over the clinical course of each patient.

Effects of a trauma center on early mortality after trauma in a regional city in Japan: a population-based study.

BACKGROUND: Although the effects of the trauma center(TC) were researched in several studies, there have been few studies on changes in the regional mortality due to the implementation of a TC. An emergency medical center (EMC) and TC were implemented at Nagasaki University Hospital (NUH) for the first time in the Nagasaki medical region of Japan in April 2010 and October 2011, respectively, and they have cooperated with each other in treating trauma patients. The purpose of this study was to investigate the effects on the early mortality at population level of a TC working in cooperation with an EMC. METHODS: This is a retrospective study using standardized regional data (ambulance service record) in Nagasaki medical region from April 2007 through March 2017. We included 19,045 trauma patients directly transported from the scene. The outcome measures were prognosis for one week. To examine the association between the implementation of the EMC and TC and mortality at a region, we fit adjusted logistic regression models. RESULTS: The number of patients of each fiscal year increased from 1492 in 2007 to 2101 in 2016. The number of all patients transported to NUH decreased until 2009 to 70, but increased after implementation of the EMC and TC. Overall mortality of all patients in the region improved from 2.3% in 2007 to 1.0% in 2016. In multivariate logistic regression model, odds ratio of death was significantly smaller at 2013 and thereafter if the data from 2007 to 2011 was taken as reference. CONCLUSIONS: Implementation of the EMC and TC was associated with early mortality in trauma patients directly transported from the scene by ambulance. Our analysis suggested that the implementation of EMC and TC contributed to the improvement of the early mortality at a regional city with 500000 populations. LEVEL OF EVIDENCE: Level III.

Novel screening criteria for post-traumatic venous thromboembolism by using D-dimer.

AIM: Because severe trauma patients frequently manifest coagulopathy, it is extremely important to detect venous thromboembolism (VTE) in the acute phase. However, no reference value for D-dimer in post-traumatic VTE has been reported given the substantial increase in its levels after injury. Therefore, this study evaluates the ability of our screening criteria using D-dimer to detect VTE in severe trauma patients. METHODS: Trauma patients (n = 455) who were admitted to our emergency medical center during October 2011-June 2015 were included in this study. To prevent VTE, intermittent pneumatic compression was carried out in most patients. Our screening criteria included the following: (i) ≥5 days of hospital stay, (ii) increasing D-dimer levels across 3 measuring days, (iii) D-dimer levels ≥15 µg/mL. Patients who met these screening criteria underwent contrast-enhanced computed tomography (CE-CT) to detect VTE. RESULTS: During the study period, 108 cases satisfied the screening criteria; 73 of these underwent CE-CT, 34 of whom were diagnosed with VTE (positive predictive value, 46.6%). The median hospital stay on satisfying the screening criteria and before undergoing CE-CT was 7 and 10 days, respectively. No patient had VTE symptoms at the time of diagnosis. Also, none of the remaining 347 patients who did not satisfy the screening criteria had VTE symptoms. CONCLUSION: The screening criteria using D-dimer presented herein can be used as reference for efficiently detecting VTE in severe trauma patients.

Association of prophylactic synbiotics with reduction in diarrhea and pneumonia in mechanically ventilated critically ill patients: A propensity score analysis.

INTRODUCTION: The preventive association of synbiotics therapy has not been thoroughly clarified in mechanically ventilated patients. The purpose of this study was to evaluate whether synbiotics therapy has preventive association against septic complications in ventilated critically ill patients. METHODS: Critically ill patients who were mechanically ventilated were included in this retrospective observational study. Patients who received synbiotics (Bifidobacterium breve, Lactobacillus casei, and galactooligosaccharides) within 3 days after admission (denoted as synbiotics group) were compared with patients who did not receive synbiotics. The incidences of enteritis, pneumonia, and bacteremia were evaluated as clinical outcome. Enteritis was defined as an acute onset of diarrhea consisting of continuous liquid watery stools for more than 12 h. The confounding factors include APACHE II on admission, gender, the cause of admission and antibiotics. RESULTS: We included 179 patients in this study: 57 patients received synbiotics and 122 patients did not receive synbiotics. The incidences of enteritis were significantly lower in the synbiotics group compared with the control group (3.5% vs. 15.6%; p < 0.05). The odds ratios for diarrhea-free days during the first 28 days for the synbiotics group as compared with the controls were 4.354 (95% confidence interval (CI), 2.407 to 7.877; p < 0.001) in an ordinal logistic regression model with propensity scores. The odds ratios for pneumonia-free days during the first 28 days for the synbiotics group were 2.529 (95% CI, 1.715 to 3.731; p < 0.001). The incidences of bacteremia did not have significant differences. CONCLUSION: Prophylactic synbiotics appeared to have preventive association on enteritis and pneumonia in mechanically ventilated critically ill patients.

The profile of Japanese Association for Acute Medicine - out-of-hospital cardiac arrest registry in 2014-2015.

AIM: To describe the registry design of the Japanese Association for Acute Medicine - out-of-hospital cardiac arrest (JAAM-OHCA) Registry as well as its profile on hospital information, patient and emergency medical service characteristics, and in-hospital procedures and outcomes among patients with OHCA who were transported to the participating institutions. METHODS: The special committee aiming to improve the survival after OHCA by providing evidence-based therapeutic strategies and emergency medical systems from the JAAM has launched a multicenter, prospective registry that enrolled OHCA patients who were transported to critical care medical centers or hospitals with an emergency care department. The primary outcome was a favorable neurological status 1 month after OHCA. RESULTS: Between June 2014 and December 2015, a total of 12,024 eligible patients with OHCA were registered in 73 participating institutions. The mean age of the patients was 69.2 years, and 61.0% of them were male. The first documented shockable rhythm on arrival of emergency medical services was 9.0%. After hospital arrival, 9.4% underwent defibrillation, 68.9% tracheal intubation, 3.7% extracorporeal cardiopulmonary resuscitation, 3.0% intra-aortic balloon pumping, 6.4% coronary angiography, 3.0% percutaneous coronary intervention, 6.4% targeted temperature management, and 81.1% adrenaline administration. The proportion of cerebral performance category 1 or 2 at 1 month after OHCA was 3.9% among adult patients and 5.5% among pediatric patients. CONCLUSIONS: The special committee of the JAAM launched the JAAM-OHCA Registry in June 2014 and continuously gathers data on OHCA patients. This registry can provide valuable information to establish appropriate therapeutic strategies for OHCA patients in the near future.

Early diagnosis using canonical discriminant analysis of innate immune receptor gene expression profiles in a murine infectious or sterile systemic inflammation model.

BACKGROUND: Infection in patients with systemic inflammation is difficult to diagnose with a single biomarker. We aimed to clarify the time course of change in the gene expression profile of innate immune receptors in infectious or sterile inflammation and to establish an early diagnostic method using canonical discriminant analysis (CDA) of the gene expression profile. METHODS: To compare infectious and sterile inflammation, we used cecal ligation and puncture (CLP) and 20% full-thickness burn injury (Burn) models. C57BL/6 mice underwent sham treatment (n = 9 × three groups), CLP (n = 12 × three groups), or Burn (n = 12 × three groups) injury. Mice were killed at 6, 12, and 24 hours after injury, and total RNA was extracted from whole blood. We used quantitative real-time polymerase chain reaction to investigate gene expression of innate immune receptors Toll-like receptor 2 (TLR2), TLR4, TLR9, NLRP3 (nucleotide-binding oligomerization domain-like receptor family pyrin domain containing 3), and retinoic acid-inducible gene I. To evaluate all gene expression together as patterns, each value was standardized, and CDA was performed at each time point. RESULTS: Gene expression of TLR2 and TLR4 was already significantly increased in both CLP and Burn compared with sham mice at 6 hours after injury (p < 0.05). Gene expression of TLR9 was significantly decreased in CLP compared with sham and Burn mice at 12 hours and 24 hours after injury (p < 0.05) but not at 6 hours. Gene expression of NLRP3 was significantly increased in CLP and Burn compared with sham mice at 6 hours and 24 hours after injury (p < 0.05). In the CDA, each group showed distinctive gene expression patterns at only 6 hours after injury. Each group was clearly classified, and the classification error rates were 0% at all of the time points. CONCLUSIONS: Canonical discriminant analysis of the gene expression profile of innate immune receptors could be a novel approach for diagnosing the pathophysiology of complicated systemic inflammation from the early stage of injury.

Delayed massive epistaxis from traumatic intracranial aneurysm after blunt facial injury.

Cases: Traumatic intracranial aneurysm following blunt head injury is uncommon but can be induced by extension of skull base fracture and causes unexpected hemorrhagic complications. We present two cases of traumatic intracranial aneurysm in the paraclinoid area that was revealed by delayed massive epistaxis. Lack of initial neurological deficits omitted screening for cerebrovascular injury. Outcome: Internal trapping was carried out using endovascular techniques in both cases, with extracranial-intracranial bypass in one case. No recurrent bleeding occurred in either case. Conclusion: To prevent unexpected delayed life-threatening hemorrhagic accidents, careful assessment of skull-base fracture is prerequisite, even in cases of mild facial injury.

An adult case of laryngopharyngeal burn by drinking hot water.

Case: A 61-year-old man who was hospitalized with schizophrenia in a psychiatric hospital drank hot water estimated to be 90°C. Eight hours after injury, laryngopharynx edema gradually progressed, and his breathing deteriorated. Upon arrival at our emergency room, we secured his respiratory tract by nasal intubation under a bronchoscope. Outcome: The edema gradually improved after peaking at hospital day 2, and he was extubated on hospital day 18. There were no apparent respiratory or esophageal problems, and he was discharged back to the psychiatric hospital on day 28. Conclusion: These types of laryngopharynx burns caused by ingesting hot foods or drinks have been rarely reported for adults. In cases of adults, when the patient is in a special situation such as having a psychiatric disorder, it is necessary to assume that the laryngopharynx burns might be aggravated.

Low total cholesterol and high total bilirubin are associated with prognosis in patients with prolonged sepsis.

PURPOSE: Nutritional biochemical indexes are generally used as markers for critically ill patients. However, they are easily influenced by acute phase changes after injury and are difficult to use as common and practical biomarkers. The objective of this study was to determine the most valuable prognostic markers among 15 common laboratory tests in patients with sepsis. METHODS: We included all sepsis patients who stayed in the intensive care unit for more than 2 weeks. We evaluated 15 biochemistry indexes including serum albumin, total protein, C-reactive protein, cholinesterase, total cholesterol (T-Cho), triglyceride, sodium, potassium, blood urea nitrogen, creatinine, aspartate aminotransferase, alanine aminotransferase, lactate dehydrogenase, total bilirubin (T-Bil), and prothrombin time. The minimum and maximum values of these indexes during the first 14 days from admission were analyzed by classification and regression tree and multivariate logistic regression analyses. RESULTS: This study comprised 91 patients with sepsis. The primary split was the minimum value of serum T-Cho (T-Cho (Min)), and the cutoff value was 73.5 mg/dL by classification and regression tree analysis. The second split was the maximum value of T-Bil (T-Bil (Max)), and the cutoff value was 1.35 mg/dL. The rate of mortality was 63% (17/27) in the group with T-Cho (Min) less than 73.5 mg/dL and T-Bil (Max) greater than 1.35 mg/dL. Multivariate logistic regression revealed that T-Cho (Min) and T-Bil (Max) were the biomarkers most closely associated with prognosis. CONCLUSIONS: Total cholesterol and T-Bil could be associated with prognosis in patients with sepsis.