An infantile traumatic brain injury with a bright tree appearance detected before the late seizure.

INDRODUCTION: Infantile traumatic brain injury (TBI) rarely follows a biphasic clinical course and exhibits a bright tree appearance (BTA) on magnetic resonance imaging (MRI). This is termed infantile traumatic brain injury with a biphasic clinical course and late reduced diffusion (TBIRD). TBIRD has clinical features similar to those of acute encephalopathy with biphasic seizures and late reduced diffusion (AESD). It remains to be clarified which patients with infantile TBI will develop TBIRD and the prevention and treatment of TBIRD. CASE AND REVIEW: We report a case of TBIRD that exhibited BTA 1 day before the late seizure and review 12 cases of TBIRD. All patients developed a subdural hematoma (SDH), were younger than 2 years, and presented with a biphasic phase within 3-6 days. The median interval between BTA and TBI was 5 days. Of the 5 cases examined with MRI before the biphasic phase, only our case was detected with BTA 4 days after TBI. CONCLUSION: Predicting the biphasic clinical course may be possible by examining MRI after TBI in patients under 2 years of age who develop SDH with unconsciousness, seizure, or hemiplegia, and these patients should be strictly followed up for 1 week.

Synthesis of arbitrary pulse waveforms in QCL-seeded ns-pulse CO2 laser for optimization of an LPP EUV source.

One of the unique features of the quantum-cascade-laser-seeded, nanosecond-pulse CO2 laser, invented for the purpose of generation of extreme UV by laser-produced-plasma, is a robust synthesis of arbitrary pulse waveforms. In the present Letter we report on experimental results that are, to our best knowledge, the first demonstration of such functionality obtainable from nanosecond-pulse CO2 laser technology. An online pulse duration adjustment within 10-40 ns was demonstrated, and a few exemplary pulse waveforms were synthesized, such as "tophat," "tailspike," and "leadspike" shapes. Such output characteristics may be useful to optimize the performance of LPP EUV source.

Efficient multiline nanosecond pulse amplification in planar waveguide CO2 amplifier for extreme UV laser-produced plasma source.

In this Letter, we report on recent experimental results of a short pulse amplification at 10.6 µm wavelength required to drive a tin laser-produced plasma (LPP) extreme ultraviolet (UV) source. We report for the first time, to our best knowledge, a highly efficient pulsed amplification in a multipass amplifier built on RF-discharge-excited, diffusion-cooled CO2, planar waveguide industrial CO2 laser. About 2 kW of output average power was obtained from about 100 W input average power in ∼15 ns pulses at 100 kHz pulse repetition frequency. As much as 60% relative extraction efficiency, as compared to continuous-wave amplification in similar conditions, and 5.8% wall-plug efficiency was recorded and believed to be the highest reported so far. An improvement of extraction efficiency by ∼10% is reported when driving the amplifier with two lines of CO2 regular band in good agreement with expectations.

Multiline short-pulse solid-state seeded carbon dioxide laser for extreme ultraviolet employing multipass radio frequency excited slab amplifier.

In this Letter we describe in more detail a solid-state seeded, nanosecond pulse, multiline CO(2) oscillator designed and built for the extreme ultraviolet (EUV) laser-produced-plasma (LPP) source. Our oscillator featured quantum cascade laser seeders, a diffraction-type seed beam combiner, and a radio-frequency-discharge-excited, diffusion-cooled, slab-waveguide CO(2) gain cell in a compact multipass regenerative amplifier configuration. The oscillator generated pulses of exceptional stability in terms of envelope, energy, and spectrum. Excellent stability of output was achieved without any additional techniques. The output spectrum consisted of two laser lines of a 00(0)1-10(0)0 band of a CO(2) molecule, P20 and P22, with a target of four lines P18-P24. The pulse duration was electronically adjustable between 11 and 35 ns at a repetition frequency from a few hertz to hundreds of kilohertz. Electronic adjustment of the pulse duration was achieved by relative timing offsets of individual seeders, opening an avenue to a range of on-line adjustments of pulse shape and spectral content timing. The jitter-tolerant operation allows for easy synchronization with an external event, such as a droplet target in an EUV LPP source. A resistance to parasitic seeding of more than 40 dB was recorded. The oscillator produced up to 20 W of average output power at a repetition rate of 100 kHz in a near-diffraction-limited beam of M(2)<1.3 and a pointing stability below 50 µrad.

Empiric antimicrobial therapy in the intensive care unit based on the risk of multidrug-resistant bacterial infection: a single-centre case‒control study of blood culture results in Japan.

BACKGROUND: Infections and sepsis are the leading causes of death in intensive care units (ICUs). Antimicrobial agent selection is challenging because the intervention is directly related to the outcome, and the problem of antimicrobial resistance (AMR) must be considered. Therefore, in this study, we aimed to clarify the epidemiological data and examine whether the detection rate of multidrug-resistant (MDR) bacteria differed depending on the presence or absence of the risk of MDR bacterial infections to establish guidance regarding the choice of antimicrobial therapy for ICU patients. METHODS: This retrospective case‒control study was performed in a single ICU in Japan. Patients admitted to the ICU who underwent blood culture (BC) analysis were considered for inclusion in this study; patients were at risk of MDR bacterial infections, and controls were not. The primary outcome measure was the detection rate of MDR bacteria in BCs collected from patients and controls. The secondary outcome measure was the selection rate of anti-Pseudomonas and anti-methicillin-resistant Staphylococcus aureus (MRSA) drugs for patients and controls. RESULTS: Among the 1,730 patients admitted to the ICU during the study period, BCs were obtained from 186 patients, and 173 samples were finally included in the analysis (n = 129 cases; n = 44 controls). No MDR bacteria or Pseudomonas aeruginosa were detected in the controls (14 (11%) vs. 0 (0%)) (P = 0.014) However, there was no difference in empiric antimicrobials, including anti-MRSA (30 (23%) vs. 12 (27%)) (P = 0.592) and anti-Pseudomonas aeruginosa (61 (47%) vs. 16 (36%)) (P = 0.208) drugs, that were administered to the two groups. CONCLUSIONS: Even in critically ill patients in the ICU, MDR bacteria are unlikely to be detected in patients without the risk of MDR bacterial infections. Therefore, for such patients, a strategy of starting empiric narrow-spectrum antimicrobial therapy rather than empiric broad-spectrum therapy should be considered. This strategy, in conjunction with daily updates of clinical and epidemiological data at each facility, will promote the appropriate use of antimicrobials and reduce the emergence of MDR bacteria in the ICU. TRIAL REGISTRATION: None.

Effect of Arginine Vasopressin on Intraoperative Hypotension Caused by Oral Administration of 5-Aminolevulinic Acid.

5-Aminolevulinic acid (5-ALA) is used for the photodynamic diagnosis of malignant tumors and has been effectively utilized to improve the complete resection rate and reduce the risk of tumor recurrence. However, intraoperative hypotension is a common adverse effect of oral 5-ALA, and it occasionally progresses to severe prolonged hypotension requiring high-dose catecholamine administration. We report a case of intraoperative hypotension due to oral 5-ALA in which arginine vasopressin (AVP) administration was effective for increasing the blood pressure. A 77-year-old man scheduled for a craniotomy for glioma was administered 5-ALA orally before surgery. After the induction of anesthesia, his blood pressure decreased substantially. Although we administered various vasopressor agents, hypotension was prolonged. However, after starting a continuous administration of AVP, the systolic blood pressure increased, and the hemodynamic parameters remained stable during the remainder of the operation. 5-ALA administration may lower blood pressure by inducing nitric oxide production, and AVP inhibits inducible nitric oxide synthase messenger RNA expression and interleukin-1ß-stimulated nitric oxide production. In light of these mechanisms, AVP may be a reasonable treatment agent for hypotension induced by 5-ALA.

Spectral characteristics of quantum-cascade laser operating at 10.6 µm wavelength for a seed application in laser-produced-plasma extreme UV source.

In this Letter, we investigate, for the first time to our knowledge, the spectral properties of a quantum-cascade laser (QCL) from a point of view of a new application as a laser seeder for a nanosecond-pulse high-repetition frequency CO(2) laser operating at 10.6 µm wavelength. The motivation for this work is a renewed interest in such a pulse format and wavelength driven by a development of extreme UV (EUV) laser-produced-plasma (LPP) sources. These sources use pulsed multikilowatt CO(2) lasers to drive the EUV-emitting plasmas. Basic spectral performance characteristics of a custom-made QCL chip are measured, such as tuning range and chirp rate. The QCL is shown to have all essential qualities of a robust seed source for a high-repetition nanosecond-pulsed CO(2) laser required by EUV LPP sources.

Wavefront measurement of single-mode quantum cascade laser beam for seed application in laser-produced plasma extreme ultraviolet system.

Quantum cascade laser (QCL) is a very attractive seed source for a multikilowatt pulsed CO2 lasers applied for driving extreme ultraviolet emitting plasmas. In this Letter, we investigate output beam properties of a QCL designed to address P18 and P20 lines of 10.6 micron band of CO2 molecule. In particular, output beam quality and stability are investigated for the first time. A well-defined linear polarization and a single-mode operation enabled a use of phase retrieval method for full description of QCL output beam. A direct, multi-image numerical phase retrieval technique was developed and successfully applied to the measured intensity patterns of a QCL beam. Very good agreement between the measured and reconstructed beam profiles was observed at distances ranging from QCL aperture to infinity, proving a good understanding of the beam propagation. The results also confirm a high spatial coherence and high stability of the beam parameters, the features expected from an excellent seed source.

Efficacy of Higher Positive End-Expiratory Pressure Ventilation Strategy in Patients With Acute Respiratory Distress Syndrome: A Systematic Review and Meta-Analysis.

Previous systematic reviews and meta-analyses assessing the pooled effects of higher positive end-expiratory pressure (PEEP) failed to show significantly reduced mortality in patients with acute respiratory distress syndrome (ARDS). Some new randomized controlled trials (RCTs) have been reported and an updated systematic review is needed to evaluate the use of higher PEEP in patients with ARDS. We searched MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Igaku-Chuo-Zasshi, ICTRP, the National Institute of Health Clinical Trials Register, and the reference list of recent guidelines. We included RCTs to compare the higher PEEP ventilation strategy with the lower strategy in patients with ARDS. Two authors independently assessed the eligibility of the studies and extracted the data. The primary outcomes were 28-day mortality. The GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) methodology was used to evaluate the certainty of the evidence. Among the 6530 screened records, 16 randomized trials involving 4150 patients were included in our meta-analysis. When comparing higher PEEP versus lower PEEP, the pooled risk ratio (RR) for 28-day mortality was 0.85 (15 studies, n=4108, 95% CI 0.72 to 1.00, I2=58%, low certainty of evidence). Subgroup analysis by study participants with a low tidal volume (LTV) strategy showed an interaction (P for interaction, 0.001). Our study showed that in patients with ARDS, the use of higher PEEP did not significantly reduce 28-day mortality compared to the use of lower PEEP.

Deaths associated with pandemic (H1N1) 2009 among children, Japan, 2009-2010.

To clarify the cause of deaths associated with pandemic (H1N1) 2009 among children in Japan, we retrospectively studied 41 patients <20 years of age who had died of pandemic (H1N1) 2009 through March 31, 2010. Data were collected through interviews with attending physicians and chart reviews. Median age of patients was 59 months; one third had a preexisting condition. Cause of death was categorized as unexpected cardiopulmonary arrest for 15 patients, encephalopathy for 15, and respiratory failure for 6. Preexisting respiratory or neurologic disorders were more frequent in patients with respiratory failure and less frequent in patients with unexpected cardiopulmonary arrest. The leading causes of death among children with pandemic (H1N1) 2009 in Japan were encephalopathy and unexpected cardiopulmonary arrest. Deaths associated with respiratory failure were infrequent and occurred primarily among children with preexisting conditions. Vaccine use and public education are necessary for reducing influenza-associated illness and death.

Additional medical costs associated with ventilator-associated pneumonia in an intensive care unit in Japan.

BACKGROUND: Additional health care costs associated with ventilator-associated pneumonia (VAP) vary widely per country; none of which have been explored in Japan. Thus, we aimed to examine the economic and clinical effects of VAP in Japan. METHODS: This was a retrospective matched case-control study of 22 patients with VAP who were treated in the intensive care unit of Yokohama Rosai Hospital between January 2012 and December 2018. Twenty-two matched controls were selected based on 5 variables (ie, sex, age, diagnosis and surgical procedure, underlying disease with or without advanced malignant tumor, and best motor response). The additional health care costs incurred owing to VAP were calculated from the difference between the mean costs of VAP and control cases. RESULTS: VAP incurred an additional cost of approximately United States Dollars (USD) 34,884 per case. The length of hospitalization itself was the major factor contributing to additional medical costs, generating a difference of 9,824 USD. DISCUSSION: VAP not only worsens patient outcomes but also generates significant additional medical costs. Patients who had developed VAP required more medical resources such as the performance of a tracheostomy. CONCLUSIONS: VAP incurs a higher mean total hospital medical cost. Thus, appropriate infection control strategies should be implemented.

Tracheal intubation using Airway Scope in two patients with difficult airway during cardiopulmonary resuscitation.

The Airway Scope AWS-S100 (AWS, Pentax, Tokyo), a rigid video laryngoscope with integrated tube guidance that has recently become commercially available, helped the authors to establish airways in two patients with in-hospital cardiopulmonary arrest, after failed attempts to intubate the patients using the Macintosh laryngoscope (that only commanded the Cormack-Lehane grade 4 glottic views), the laryngeal mask airway, and even surgical cricothyroidotomy for the second case. This showed the utility of the AWS in the management of difficult airway cases even in emergency settings.

A case of complete atrioventricular block in secondary hemophagocytic syndrome/hemophagocytic lymphohistiocytosis recovered by plasma exchange and cytokine absorbing therapy with AN69ST continuous hemodiafiltration.

We report a case of incipient systemic lupus erythematosus (SLE) that rapidly progressed to complete atrioventricular block (cAVB). A 20-year-old man was admitted with facial erythema, painless oral aphtha, polyarthritis, and myalgia of each extremity. On admission, he developed first-degree atrioventricular block, pericarditis, pleuritis, renal failure, hemophagocytic lymphohistiocytosis, neurophychiatric SLE (left cerebellar infarction), and Staphylococcus aureus bacteremia. He was subsequently diagnosed with SLE based on several positive findings on immunological tests (including positive for antinuclear antibody). Despite immediate glucocorticoid pulse therapy and plasma exchange (PE) along with antibiotic, he developed cAVB that required temporary pacing on day 2. Because it was thought that hypercytokinemia exacerbated pericarditis, which progressed to myocarditis and cAVB, we decided to PE and cytokine-adsorbing therapy with AN69ST-continuous hemodiafiltration (CHDF). Other than renal failure, his organ dysfunctions improved with the multidisciplinary therapy. CAVB improved and temporary pacing was no longer required on day 11. Even a first-degree atrioventricular block can rapidly progress to cAVB; therefore, strict attention to electrocardiogram is necessary in severe SLE cases. When presenting with organ dysfunctions caused by hypercytokinemia such as severe SLE cases or SLE with severe infection cases, use of the combination of PE and AN69ST-CHDF might be beneficial.

TLR4 signaling is essential for survival in acute lung injury induced by virulent Pseudomonas aeruginosa secreting type III secretory toxins.

BACKGROUND: The relative contributions of the cytotoxic phenotype of P. aeruginosa expressing type III secretory toxins and an immunocompromised condition lacking normal Toll-like receptor 4 (TLR4) signaling in the pathogenesis of acute lung injury and sepsis were evaluated in a mouse model for Pseudomonas aeruginosa pneumonia. By using lipopolysaccharide-resistant C3H/HeJ mice missing normal TLR4 signaling due to a mutation on the tlr4 gene, we evaluated how TLR4 signaling modulates the pneumonia caused by cytotoxic P. aeruginosa expressing type III secretory toxins. METHODS: We infected C3H/HeJ or C3H/FeJ mice with three different doses of either a cytotoxic P. aeruginosa strain (wild type PA103) or its non-cytotoxic isogenic mutant missing the type III secretory toxins (PA103DeltaUT). Survival of the infected mice was evaluated, and the severity of acute lung injury quantified by measuring alveolar epithelial permeability as an index of acute epithelial injury and the water to dry weight ratios of lung homogenates as an index of lung edema. Bacteriological analysis and cytokine assays were performed in the infected mice. RESULTS: Development of acute lung injury and sepsis was observed in all mouse strains when the cytotoxic P. aeruginosa strain but not the non-cytotoxic strain was instilled in the airspaces of the mice. Only C3H/HeJ mice had severe bacteremia and high mortality when a low dose of the cytotoxic P. aeruginosa strain was instilled in their lungs. CONCLUSION: The cytotoxic phenotype of P. aeruginosa is the critical factor causing acute lung injury and sepsis in infected hosts. When the P. aeruginosa is a cytotoxic strain, the TLR4 signaling system is essential to clear the bacteria to prevent lethal lung injury and bacteremia.

Effects of monoclonal anti-PcrV antibody on Pseudomonas aeruginosa-induced acute lung injury in a rat model.

BACKGROUND: The effects of the murine monoclonal anti-PcrV antibody Mab166 on acute lung injury induced by Pseudomonas aeruginosa were analyzed in a rat model. METHODS: Lung injury was induced by the instillation of P. aeruginosa strain PA103 directly into the left lungs of anesthetized rats. One hour after the bacterial instillation, rabbit polyclonal anti-PcrV IgG, murine monoclonal anti-PcrV IgG Mab166 or Mab166 Fab-fragments were administered intratracheally directly into the lungs. The degree of alveolar epithelial injury, amount of lung edema, decrease in oxygenation and extent of lung inflammation by histology were evaluated as independent parameters of acute lung injury. RESULTS: These parameters improved in rats that had received intratracheal instillation of either rabbit polyclonal anti-PcrV IgG, murine monoclonal anti-PcrV IgG Mab166 or Mab166 Fab-fragments in comparison with the control group. CONCLUSION: Mab166 and its Fab fragments have potential as adjuvant therapy for acute lung injury due to P. aeruginosa pneumonia.

[The effects of inhaled carbon monoxide on lung injury in rats caused by lipopolysaccharide].

BACKGROUND: Carbon monoxide (CO) has long been considered a toxic substance. Recent studies have revealed that CO may play an important role in intercellular signaling. We hypothesized that CO modulates the inflammatory mechanisms. METHODS: SD rats (each study group consisting of 7 animals) inhaled 250 ppm of CO one hour prior to LPS challenges. These animals were incubated for a particular period of time (four different length of time; 1, 2, 4, and 8 hours). The control group (each study group consisting of 6 animals) had been left in the room air. Both groups were instilled with LPS (1 mg) into the lungs. At the end of each period, animals were exsanguinated, broncho-alveolar lavage (BAL) and blood sampling were performed, and a part of the small intestine was harvested. PMN numbers, protein, TNF, and IL-10 concentrations in BAL fluid were measured. Plasma TNF and IL-10 were also measured. The Wet/Dry ratio of a small intestine was calculated. RESULTS: In the CO-inhalation group, the anti-inflammatory cytokine IL-10 concentration in the BAL fluid was higher at 8 hours after LPS challenge than the counterpart of room air group (37.6 +/- 11.4 pg.ml-1 vs. 92.8 +/- 31.5 pg.ml-1, P < 0.05). W/D ratio decreased (3.29 +/- 0.2 vs. 2.94 +/- 0.06, P < 0.05). CONCLUSION: These findings indicated that CO inhalation might modulate the inflammatory response to LPS. Further study is needed to prove the therapeutic role of CO inhalation without serious adverse effects.

Severe form of encephalopathy associated with 2009 pandemic influenza A (H1N1) in Japan.

BACKGROUND: Every year, an estimated 200-500 children in Japan develop influenza-associated encephalopathy (IAE), and 10-30% of these children die. OBJECTIVE: To clarify the clinical features of a severe form of acute encephalopathy seen with 2009 pandemic influenza A (H1N1). STUDY DESIGN: This retrospective survey examined 20 children with acute encephalopathy associated with the 2009 pandemic influenza A (H1N1) who died or were in a prolonged deep coma with a flat electroencephalogram tracing and loss of spontaneous respiration. We obtained demographic, clinical, laboratory, and neuroimaging data through interviews with the attending physicians and chart reviews. RESULTS: Subjects were 13 boys and seven girls. Their median age was 45 (range 11-200) months. Five patients had one or more pre-existing conditions. Acute encephalopathy developed within 2 days after influenza onset in 16 patients. As the initial neurological symptom, delirious behavior was seen in six children, and brief seizures in six. Eighteen patients were comatose within 6h of the onset of encephalopathy. Marked brain edema on computed tomography (CT) was seen in all but one patient. Brainstem lesions on CT were recognized in 12 patients. Sixteen patients died 0-45 (median 2.5) days after the onset of acute encephalopathy, and the others remained in deep comas without spontaneous respiration. CONCLUSIONS: The clinical course of the patients was characterized by an onset with mild neurological symptoms and rapid deterioration of consciousness into coma. Head CT revealed marked cerebral edema, often associated with brainstem lesions.

Acute encephalopathy in two cases with severe congenital hydrocephalus.

We report acute encephalopathy in two cases with severe congenital hydrocephalus. Case 1 was a 23-month-old girl, born at of 36weeks gestation and delivered by cesarean section due to congenital hydrocephalus. Magnetic resonance imaging (MRI) showed prominent ventricular dilation associated with hydrocephalus, Dandy-Walker variant and cortical malformation. The blood test for toxoplasmosis, syphilis, varicella-zoster, rubella, cytomegalovirus, and herpes simplex virus (TORCH) complex and various metabolic tests of blood and urine specimens yielded unremarkable results. She was admitted to our hospital for respiratory failure with fever and her clinical course deteriorated, progressing to hemiconvulsion hemiplegia epilepsy syndrome. Case 2 was a 17-month-old boy, born by spontaneous vertex delivery at 39weeks. Severe, asymmetrical ventricular dilation associated with hydrocephalus, cerebellar and brainstem hypoplasia, and punctuate calcifications of the thalamus, third and fourth ventricles, around the aqueduct, were observed on computed tomography (CT). The blood test for TORCH complex and various metabolic tests of blood and urine specimens yielded unremarkable results. He was admitted to our hospital for status epilepticus with fever and his clinical course progressed to hemorrhagic shock and encephalopathy syndrome. In patients with brain disorders, diagnosis and treatment are likely to be delayed and prognosis may thereby be worsened. When status epileptics or prolonged coma manifests even in patients with severe brain disorders, we must consider encephalopathy in the differential diagnosis.

A simple method to reduce the inspiratory oxygen fraction for high pulmonary blood flow patients in an operating room.

BACKGROUND: Low inspired oxygen acutely increases pulmonary vascular resistance and decreases pulmonary-systemic blood flow ratio. We present a simple method to lower inspired oxygen fraction (FIO2<0.21) without supplemental nitrogen, during mechanical ventilation by an anesthesia machine. METHODS: After institutional approval, seven healthy adult volunteers and three infants (0-12 month old) scheduled for congenital heart surgery were enrolled in this study. All the infants were diagnosed with congestive heart failure because of high pulmonary blood flow and were thought to benefit from low FIO2. The volunteers performed spontaneous ventilation (fresh air flow rate=10 l.min(-1), tidal volume=600 ml, frequency=10 br.min(-1)). The infants were mechanically ventilated with air (fresh air flow rate=6 l.min(-1), tidal volume=10 ml.kg(-1), 1515%, fresh gas flow rates were increased to adjust FIO2 to 0.21. RESULTS: In all of the seven volunteers and three infants target FIO2 was achieved in <10 min. FIO2 was kept at 0.18+/-0.01 (SD) by calculated fresh air flow rates. In one infant, SpO2 decreased >15% 20 min after lowering FIO2, we had to discontinue this study, and increase fresh gas flow to ventilate the infant with FIO2 0.21. In the other two infants, FIO2 was maintained throughout the study. CONCLUSIONS: This simple and convenient method to decrease FIO2, has a utility in clinical situations, in which pulmonary vascular resistance is to be increased to improve systemic oxygen delivery in patients with high pulmonary blood flow during cardiac surgery.