Heart Rate and Mortality After Resuscitation in Patients With Out-of-Hospital Cardiac Arrest　- Insights From the SOS-KANTO Registry.

BACKGROUND: Heart rate (HR) predicts outcomes in patients with acute coronary syndrome (ACS), whereas the impact of HR on outcomes after out-of-hospital cardiac arrest (OHCA) remains unclear. This study aimed to investigate the impact of HR after resuscitation on outcomes after OHCA and whether the impact differs with OHCA etiology.Methods and Results: Of 16,452 patients suffering from OHCA, this study analyzed 741 adults for whom HR after resuscitation was recorded by 12-lead electrocardiogram upon hospital arrival. Etiology of OHCA was categorized into 3 groups: ACS, non-ACS, and non-cardiac. Patients in each etiology group were further divided into tachycardia (>100 beats/min) and non-tachycardia (≤100 beats/min). The impact of HR on outcomes was evaluated in each group. Among the 741 patients, the mean age was 67.6 years and 497 (67.1%) patients were male. The primary outcome - 3-month all-cause mortality - was observed in 55.8% of patients. Tachycardia after resuscitation in patients with ACS was significantly associated with higher all-cause mortality at 3 months (P=0.002), but there was no significant association between tachycardia and mortality in non-ACS and non-cardiac etiology patients. In a multivariate analysis model, the incidence of tachycardia after resuscitation independently predicted higher 3-month all-cause mortality in OHCA patients with ACS (hazard ratio: 2.17 [95% confidence interval: 1.05-4.48], P=0.04). CONCLUSIONS: Increased HR after resuscitation was associated with higher mortality only in patients with ACS.

Urinary liver-type fatty acid-binding protein variation as a predictive value of short-term mortality in intensive care unit patients.

BACKGROUND: Predicting the prognosis of intensive care unit (ICU) patients is crucial because it may lead to patient stratification that would in turn help in appropriately distributing limited medical resources. This study, therefore, aimed to investigate the use of the urinary liver-type fatty acid-binding protein (L-FABP) semi-quantitative kit in rapidly predicting the prognosis of patients admitted to the ICU. METHODS: We conducted a single-center, prospective, observational study wherein 100 consecutive patients admitted to the ICU with an indwelling bladder catheter were enrolled between April and October 2020. Urine specimens were collected at the time of admission (T1) and after 6 h (T2), and urinary L-FABP levels were semi-quantitatively measured. Based on the results, an L-FABP variation was defined as the change in L-FABP (negative, weakly positive, or strongly positive) from T1 to T2. Patients were divided into three groups (L-FABP decreased group, unchanged group, or increased group), following which we compared their 14-day mortality. RESULTS: Finally, a total of 79 patients were included in the analysis. In multivariate analysis, urinary L-FABP variation [Odds ratio (OR) = 14.327, 95% confidence interval (CI) = 1.819-112.868, p = 0.01] and lactate (OR = 1.234, 95%CI = 1.060-1.437, p = 0.01) were significantly associated with 14-day mortality. CONCLUSION: Urinary L-FABP variation at 6 h after admission was significantly associated with 14-day mortality.

Streptococcal toxic shock syndrome caused by ß-hemolytic streptococci: Clinical features and cytokine and chemokine analyses of 15 cases.

OBJECTIVES: ß-Hemolytic streptococci occasionally cause severe infections such as necrotizing fasciitis and streptococcal toxic shock syndrome (STSS). Here, we conducted a prospective study to investigate the production of cytokines and chemokines in patients with STSS to explore its pathogenesis in survivors and fatal cases. METHODS: From January 2013 through August 2015, all culture results from normally sterile sites were prospectively followed and screened for STSS. Clinical characteristics of the patients with STSS were evaluated and compared between survivors and fatal cases. Serum samples were collected on admission for quantification of various cytokines and chemokines. Bacterial strains were categorized by Lancefield grouping and analyzed for the emm type, and presence of speA, speB, speC, and speF. RESULTS: Fifteen patients received diagnosis of STSS. The median age of the patients was 60-year-old, and the mortality rate was 40% despite intensive treatment. Nine strains were categorized as group A, two belonged to group G, and four to group B. Group A contained various emm genotypes. Unexpectedly, potent proinflammatory cytokine levels such as TNF-α and IL-1ß were not significantly elevated, and comparison with surviving patients showed that IL-6, IL-8, and MCP-1 levels were significantly decreased and creatine kinase level was significantly elevated in fatally ill cases. CONCLUSION: Our results indicate that reduced production of proinflammatory cytokines and chemokines may be involved in STSS pathogenesis and critical for prognosis of patients with STSS.

Consideration of the Intracranial Pressure Threshold Value for the Initiation of Traumatic Brain Injury Treatment: A Xenon CT and Perfusion CT Study.

BACKGROUND: Monitoring of intracranial pressure (ICP) is considered to be fundamental for the care of patients with severe traumatic brain injury (TBI) and is routinely used to direct medical and surgical therapy. Accordingly, some guidelines for the management of severe TBI recommend that treatment be initiated for ICP values >20 mmHg. However, it remained to be accounted whether there is a scientific basis to this instruction. The purpose of the present study was to clarify whether the basis of ICP values >20 mmHg is appropriate. SUBJECT AND METHODS: We retrospectively reviewed 25 patients with severe TBI who underwent neuroimaging during ICP monitoring within the first 7 days. We measured cerebral blood flow (CBF), mean transit time (MTT), cerebral blood volume (CBV), and ICP 71 times within the first 7 days. RESULTS: Although the CBF, MTT, and CBV values were not correlated with the ICP value at ICP values ≤20 mmHg, the CBF value was significantly negatively correlated with the ICP value (r = -0.381, P < 0.05) at ICP values >20 mmHg. The MTT value was also significantly positively correlated with the ICP value (r = 0.638, P < 0.05) at ICP values >20 mmHg. CONCLUSION: The cerebral circulation disturbance increased with the ICP value. We demonstrated the cerebral circulation disturbance at ICP values >20 mmHg. This study suggests that an ICP >20 mmHg is the threshold to initiate treatments. An active treatment intervention would be required for severe TBI when the ICP was >20 mmHg.

Coloration Phenomenon of Flunitrazepam on the Tongue of an Elderly Patient: A Case Report.

Patients with dementia may forget to take their oral medications or may accidentally take too much. Furthermore, there are cases where people lick the medicine without recognizing it as a medicine or accidentally ingest it. An 88-year-old woman with a history of insomnia presented to the hospital, complaining of her weakness and mild loss of consciousness. Although her blood tests, imaging studies, and neurological findings were unremarkable, we noticed that her tongue was blue and determined that she had mistakenly taken flunitrazepam. This accidental ingestion was diagnosed as the cause of the symptoms. Patients with dementia report that they may take medicine by licking it, and some oral medicines have a coloring effect.

Repeated Hemolytic Streptococcal Infections in Soft Tissue Eosinophilic Granulomatosis (Kimura's Disease): A Case Report.

Soft tissue eosinophilic granulomatosis (Kimura's disease) is an eosinophilic granuloma with a proliferation of lymphoid follicles in the subcutaneous soft tissue. Although no established treatment exists, it is considered a disease with a good prognosis. On the other hand, bacteremia caused by group G hemolytic streptococcus (GGS) is said to be caused by chronic local lymph abnormalities and is likely to recur. We present the case of a 41-year-old Japanese man. He had a history of treatment for Kimura's disease and sepsis due to hemolytic streptococcus and came to our hospital with a chief complaint of fever. His blood culture revealed hemolytic streptococcus, and he was admitted to the hospital. Kimura's disease involves the proliferation of lymphoid follicles, so when blood cultures repeatedly turn positive, it is important to treat the patient with a GGS infection in mind.

High-Pressure Injection Damage Caused by a High-Pressure Washer.

High-pressure injection injuries, caused by forcefully injecting liquids or gases into the body, present significant challenges in diagnosis and treatment. Complications such as infection and compartment syndrome can occur, leading to various outcomes, including the possibility of amputation. Treatment approaches vary, with some cases undergoing surgery and others opting for conservative methods. However, due to the rarity of this injury, clear treatment guidelines are lacking. Consequently, there is insufficient data to establish specific guidelines, such as the duration of antibiotic treatment, necessity of surgery, and timing of rehabilitation intervention. While emergency surgery may be required, limited reports of detailed CT or MRI examinations being conducted before the surgical procedure are available. This case report involves an initial assessment, including physical examination, X-rays, CT scans, and MRI, to determine whether surgical or conservative treatment is appropriate. The laboratory risk indicator for necrotizing fasciitis (LRINEC) score assists in evaluating the risk of infection, and MRI plays a crucial role in predicting complications.

Early cerebral circulation disturbance in patients suffering from different types of severe traumatic brain injury: a xenon CT and perfusion CT study.

INTRODUCTION: Traumatic brain injury (TBI) is widely known to cause dynamic changes in cerebral blood flow (CBF). In particular, secondary brain insults have been reported to decrease CBF. The purpose of this study was to clarify the cerebral circulation in different types of TBI. METHODS: Sixty-nine patients with TBI were divided into four groups, the subdural hematoma group, the contusion/intracerebral hematoma group, the diffuse axonal injury group, and the diffuse brain swelling group. In these patients, we simultaneously performed Xe-CT and perfusion CT to evaluate the cerebral circulation on post-injury days 1-3. We measured CBF using Xe-CT and mean transit time using perfusion CT and calculated the cerebral blood volume using the AZ-7000 W98 computer system. RESULTS: There were no significant differences in the Glasgow Coma Scale score on arrival or the Glasgow Outcome Scale score between the groups. The patients who had suffered focal TBI displayed more significant cerebral circulation disturbances than those that had suffered diffuse TBI. We were able to evaluate the cerebral circulation of TBI patients using these parameters. CONCLUSION: Moderate hypothermia therapy, which decreases CBF, the cerebral metabolic rate oxygen consumption (CMRO2), and intracranial pressure might be effective against the types of TBI accompanied by cerebral circulation disturbance. We have to use all possible measures including hypothermia therapy to treat severe TBI patients according to the type of TBI that they have suffered.

Pain in the penis due to attraction caused by neodymium magnets.

Multiple neodymium magnets can pinch tissue and cause barotrauma. Be careful if the tissue of the penis or foreskin is pinched, as this may cause foreskin necrosis or damage to the urethra.

Physical findings of crowned dens syndrome.

If meningitis is suspected, head computed tomography is performed before cerebrospinal fluid collection. Crown dens syndrome can be diagnosed using simultaneous CT scans of the head and neck. Thus, unnecessary CSF tap test can be avoided.

Pounding score of intracranial lipomas.

Most intracranial lipomas are asymptomatic, but headache is the most common symptom. The pounding score is sometimes high. Therefore, it is necessary to monitor imaging findings in parallel with the treatment of migraine.

The Experience of Using Urinary Liver-Type Fatty Acid-Binding Protein for Follow-Up of Toluene Poisoning: A Case Report.

Toluene poisoning is diagnosed based on toluene exposure history and the level of hippuric acid in the urine. Regular blood and urine tests are performed for follow-up. A 54-year-old man collided with a utility pole while driving a car and was rushed to our hospital with a complaint of loss of consciousness. Although the trauma was minor, toluene poisoning was suspected based on the presence of impaired consciousness, occupation is a painting job that involves toluene, and the presence of metabolic acidosis of the normal anion gap. Urinary hippuric acid and urinary liver-type fatty acid-binding protein (L-FABP) were measured, and a diagnosis of renal tubular acidosis (RTA) due to toluene toxicity was made. Urinary L-FABP levels decreased as the condition improved. Urinary L-FABP is a practical and rapid diagnostic and follow-up tool for toluene-induced RTA, and it is helpful to measure it in addition to conventional methods.

Comorbidity Between Crowned Dens Syndrome and Primary Hyperparathyroidism.

Primary hyperparathyroidism (PHPT) is characterized by various symptoms, including malaise, psychiatric symptoms, and hypertension. When hypercalcemia is accompanied by PHPT, it may cause pathologic fractures or lethargy. Additionally, PHPT can be complicated by crowned dens syndrome (CDS). We present a case of a 72-year-old female. She had begun experiencing low back pain during movement five days before. The symptoms progressed and the patient was unable to move. Based on the imaging, blood tests, and clinical findings, the patient was diagnosed with PHPT complicated with CDS. Therefore, it is important to perform a careful physical examination of the neck and cervical spine computed tomography in patients with PHPT. Moreover, measuring calcium levels in patients with CDS may lead to early detection of PHPT.

Improved Neurological Outcome of Perampanel for Hypoxic-Ischemic Encephalopathy in Patients After Out-of-Hospital Cardiac Arrest Resuscitation.

BACKGROUND: Although the resuscitation rate for out-of-hospital cardiac arrest (OHCA) patients in Japan is increasing due to the widespread use of automated external defibrillators, the proportion of patients who can return to society remains low at approximately 7%. Many patients have poor neurological outcomes and cannot return to society because of post-resuscitation hypoxic-ischemic encephalopathy. While the resumption of cardiac rhythm is important for patients with OHCA, improving neurological outcomes and returning to society are also important. OBJECTIVES: To investigate whether perampanel, an antiepileptic drug that provides neurological protection against stroke and head injury, could improve neurological outcomes in patients resuscitated after OHCA. METHODS: The participants included 33 patients with OHCA admitted to our hospital from January 2021 to June 2022 and 33 patients admitted before that time. Perampanel was administered to the patients in the intervention group immediately after resuscitation. We defined a Cerebral Performance Category (CPC) score of 1.2 as a good neurological outcome. RESULTS: There was no significant difference in neurological outcomes at intensive care unit discharge between the intervention and non-intervention groups (number of CPC 1.2: 16/33 vs. 9/33); however, neurological outcomes at hospital discharge were significantly better in the intervention group (number of CPC 1.2: 19/33 vs. 9/33 P = 0.01). CONCLUSION: The α-amino-3-hydroxyl-5-methyl-4-isoxazole-propionate receptor inhibitory and neuronal protective effects of perampanel may have inhibited the progression of hypoxic-ischemic encephalopathy, which develops after the resumption of cardiac rhythm, and suppressed neuronal damage. Early administration of perampanel after resuscitation of patients with OHCA may improve neurological outcomes.

Use of Maximum Tongue Pressure Values to Examine the Presence of Dysphagia after Extubation and Prevent Aspiration Pneumonia in Elderly Emergency Patients.

Background: Tongue pressure values in patients with dysphagia are reported to be significantly lower than those in healthy controls. The aim of this study was to measure the maximum tongue pressure (MTP) values after extubation in order to assess the presence of post-extubation dysphagia for the safe initiation of oral intake in elderly patients. Methods: Data from 90 patients who were extubated after mechanical ventilation under tracheal intubation were collected retrospectively. The patients were divided into two groups as follows: normal group (those who did not develop aspiration pneumonia after extubation; median age 62 years) and aspiration group (those who developed aspiration during the evaluation period; median age 75 years). The MTP values were measured at 6 h, 24 h, 3 days, and 7 days after extubation. Results: The values were significantly increased 24 h after extubation in the normal group (p < 0.05). Alternatively, no increase was observed even after 1 week of extubation in the aspiration group, and the values were significantly lower than those in the normal group. The cutoff values at 6 and 24 h after extubation, which were measured using the receiver operator characteristic (ROC) curve, were 17.8 and 23.2 kpa, respectively; furthermore, the results of these assessments were strongly related to the development of aspiration 6 h after extubation (χ2-value: 6.125; p = 0.0133). Conclusions: The presence of post-extubation dysphagia in patients who are intubated for ≥24 h can be predicted based on age and the MTP values at 6 h after extubation.

Intramucosal esophageal dissection caused by gastric tube insertion.

We experienced a case of iatrogenic intramucosal esophageal dissection in a patient who had difficulty inserting a gastric tube. CT is useful for diagnosis.

Association of red blood cell and platelet transfusions with persistent inflammation, immunosuppression, and catabolism syndrome in critically ill patients.

The objective of this single-center retrospective cohort study was to investigate the relationship between blood transfusion and persistent inflammation, immunosuppression, and catabolism syndrome (PIICS). The study was conducted at the Critical Care Center at Toho University Omori Medical Center, Japan. We included 391 patients in the PIICS group (hospitalization for > 15 days, C-reactive protein > 3.0 mg/dL or albumin < 3.0 mg/dL or lymph < 800/µL on day 14) and 762 patients in the non-PIICS group (hospitalization for > 15 days and not meeting the PIICS criteria). We performed univariate and multivariate logistic regression analyses using PIICS as the objective variable and red blood cell (RBC) or fresh frozen plasma or platelet (PLT) transfusion and other confounding factors as explanatory variables. In addition, we conducted a sensitivity analysis using propensity score matching analysis. The multivariate and propensity score analyses showed that RBC and PLT transfusions were significantly associated with PIICS. This is the first study to report an association between RBC and PLT transfusions and PIICS. Our findings have contributed to better understanding the risk factors of PIICS and suggest that physicians should consider the risk of PIICS occurrence when administering blood transfusions in intensive care unit (ICU) patients.

Urinary liver-type fatty acid-binding protein: A hemodynamic index during extracorporeal membrane oxygenation.

We discuss a case in which urinary L-FABP measurements were used to manage a 46-year-old male patient receiving V-A ECMO support. His mean blood pressure was ≥75 mmHg for the first 24 h after the initiation of V-A ECMO, and he experienced a rapid decrease in urinary L-FABP levels.

Early mobilisation using a mobile patient lift in the intensive care unit: protocol for a randomised controlled trial.

INTRODUCTION: It is important to prevent the deterioration of activities of daily living to improve the long-term prognoses of patients in the intensive care unit (ICU). The patients' conditions, along with the lack of human and technical resources, often become barriers to achieving early mobilisation after the introduction of mechanical ventilation. We plan to verify the usefulness of a mobile patient lift for early mobilisation. METHODS AND ANALYSIS: We will conduct a single-centre, open-label, randomised controlled trial. The inclusion criteria are as follows: age ≥18 years, independent walking before admission and expected mechanical ventilation for at least 48 hours. The participants will be randomly divided into groups with (intervention group) or without (control group) a mobile lift protocol. A mobile lift will be used in the intervention group. The primary endpoint will be the number of days required to achieve an ICU mobility scale of ≥4 (standing position). The results of the two groups will be analysed using the Student's t-test. ETHICS AND DISSEMINATION: This study will be conducted in accordance with the Declaration of Helsinki and with the approval of the Toho University Omori Medical Center Ethics Committee (approval number M20259). The results of this study will be presented internationally at academic conferences and published in the literature. TRIAL REGISTRATION NUMBER: UMIN000044965.

Plasma filtration with dialysis for the treatment of capillary leak syndrome occurring secondary to surgery for colon cancer-related perforating peritonitis.

The use of plasma filtration with dialysis (PDF) may be considered when treating the acute phase of capillary leak syndrome (CLS). To the best of our knowledge, this is the first report using PDF for CLS.