Reverse Shock Index multiplied by Glasgow Coma Scale score as a point-of-care severity assessment for initial trauma management: A nationwide cohort study.

BACKGROUND: Severe trauma patients often require emergent interventions, such as massive transfusion, resuscitative procedures, and surgical procedures, and consume considerable human and medical resources. However, few practical indices can be easily used for emergent interventions. In recent years, it has become clear that rSIG (Reverse Shock Index multiplied by Glasgow Coma Scale [GCS] score), which can be easily calculated from vital signs, is a promising predictor of mortality. However, it is unclear whether rSIG is useful for emergent interventions. METHODS: Data collected by the Japan Trauma Data Bank for adult patients admitted directly from the scene of trauma between April 2019 and December 2020 were analysed. The outcomes were massive transfusion, resuscitative procedures, surgical procedures and emergent interventions. Emergent interventions were defined as the composite outcome of massive transfusion, resuscitative procedures, and surgical procedures. The ability of rSIG to predict massive transfusion was compared with that of the ABC score and FASILA score by receiver-operating characteristic curve analysis. The ability of rSIG to predict resuscitative and surgical procedures was compared with that of the Shock Index (SI), GCS, Triage Revised Trauma score (T-RTS), and Previous Simple Prediction (PSP) score. The ability of rSIG to predict emergent interventions was compared with that of T-RTS, PSP, ABC, and FASILA. In addition to rSIG, rSIM (Reverse Shock Index multiplied by best motor response score) was also analysed as a supplement. RESULTS: The study included 32,201 patients, 6,371 of whom required emergent interventions. The area under the receiver-operating characteristic curve (AUROC) for massive transfusion was highest for rSIG (0.846 [95 % confidence interval 0.832-0.859]) and significantly higher for rSIG than for rSIM, ABC and FASILA (all p < 0.0001). AUROCs for resuscitative and surgical procedures were highest for rSIG (0.777 [0.769-0.785] and 0.731 [0.720-0.741], respectively) and significantly higher than those for rSIM, SI, GCS, T-RTS, and PSP (all p < 0.0001). The AUROC for emergent interventions was highest for rSIG (0.760 [0.753-0.768]) and significantly higher for rSIG than for rSIM, T-RTS, PSP, ABC, or FASILA (all p < 0.0001). CONCLUSIONS: rSIG is a simple and effective point-of-care predictor of emergent interventions during initial management of trauma.

Quantitative analysis of the skull in the Japanese wolf (Canis lupus hodophilax) using CT.

In this study using computed tomography (CT), the volumes of the internal cranial cavities, such as the braincase, frontal sinus and tympanic cavity, and the ratio of the volume of each cavity to the skull volume in Japanese wolves were quantified, and CT images of the frontal sinus were observed. The results were then compared with those of other wolf subspecies, including Akita, a dog breed, to clarify the characteristics of the internal cranial cavities in Japanese wolves. The present study revealed that the Japanese wolf had a relatively larger braincase volume and a relatively smaller frontal sinus volume than the wolf ssp. (a group of wild wolf subspecies except the Japanese wolf) and Akita. Moreover, the relative and absolute tympanic cavity volumes of the Japanese wolf and Akita were significantly smaller than those of the wolf ssp. In the CT image or macroscopic observations, the frontal sinuses of the wolf ssp. and Akita were relatively well developed to the caudal and dorsal directions, respectively, compared with that of the Japanese wolf, and the tympanic cavity of the wolf ssp. was more largely swelled ventrally and medially than that of other groups.

The reverse shock index multiplied by the Glasgow Coma Scale score can predict the need for initial resuscitation in patients suspected of sepsis.

For patients suspected of sepsis, early recognition of the need for initial resuscitation is key in management. This study evaluated the ability of a modified shock index - the reverse shock index multiplied by the Glasgow Coma Scale score (rSIG) - to predict the need for initial resuscitation in patients with sepsis. This retrospective study involved adults with infection who were admitted to a Japanese tertiary care hospital from an emergency department between January and November 2020. The rSIG, modified Early Warning Score (MEWS), quick Sequential Organ Failure Assessment (qSOFA), and original shock index (SI) values were recorded using initial vital signs. The primary outcome was the area under the receiver-operating characteristic curve (AUROC) for the composite outcome consisting of vasopressor use, mechanical ventilation, and 72-h mortality. Secondary outcomes were the AUROCs for each component of the primary outcome and 28-day mortality. As a result, the primary outcome was met by 67 of the 724 patients (9%). The AUROC was significantly higher for the rSIG than for the other tools (rSIG 0.84 [0.78 - 0.88]; MEWS 0.78 [0.71 - 0.84]; qSOFA 0.72 [0.65 - 0.79]; SI 0.80 [0.74 - 0.85]). Compared with MEWS and qSOFA, the rSIG also had a higher AUROC for vasopressor use and mechanical ventilation, but not for 72-h mortality or in-hospital mortality. The rSIG could be a simple and reliable predictor of the need for initial resuscitation in patients suspected of sepsis.

Evaluation of a bundle approach for the prophylaxis of ventilator-associated pneumonia: A retrospective single-center Study.

Ventilator-associated pneumonia (VAP) is defined as pneumonia occurring after the first 48 hours of intubation and mechanical ventilation and is the most frequent hospital-acquired infection associated with intensive care unit (ICU) admissions. Herein, we defined a novel VAP bundle including 10 preventive items. We analyzed compliance rates and clinical effectiveness associated with this bundle in patients undergoing intubation at our medical center. A total of 684 consecutive patients who underwent mechanical ventilation were admitted to the ICU between June 2018 and December 2020. VAP was diagnosed by at least two physicians based on the relevant United States Centers for Disease Control and Prevention criteria. We retrospectively evaluated associations between compliance and VAP incidence. The overall compliance rate was 77%, and compliance generally remained steady during the observation period. Moreover, although the number of ventilatory days remained unchanged, the incidence of VAP improved statistically significantly over time. Low compliance was identified in four categories: head-of-bed elevation of 30- 45º, avoidance of oversedation, daily assessment for extubation, and early ambulation and rehabilitation. The incidence of VAP was lower in those with an overall compliance rate of ≥ 75% than its incidence in the lower compliance group (15.8 vs. 24.1%, p = 0.018). When comparing low-compliance items between these groups, we found a statistically significant difference only for daily assessment for extubation (8.3 vs. 25.9%, p = 0.011). In conclusion, the evaluated bundle approach is effective for the prophylaxis of VAP and is thus eligible for inclusion in the Sustainable Development Goals.

Fluid resuscitation of at least 30 mL/kg was not associated with decreased mortality in patients with infection, signs of hypoperfusion, and a do-not-intubate order.

Aim: Administration of at least 30 mL/kg of fluid as fluid resuscitation is recommended for patients with sepsis and signs of hypoperfusion. However, it is not clear whether this is appropriate for patients with a do-not-intubate (DNI) order. This study evaluated the association between volume of fluid resuscitation and outcomes in patients with infection, signs of hypoperfusion, and a DNI order in an emergency department. Methods: This was a single-center retrospective cohort study. We classified the infected patients with signs of hypoperfusion and a DNI order seen in our emergency department between April 1, 2015 and November 31, 2020 into the standard fluid resuscitation group (≥30 mL/kg) and the restricted fluid resuscitation group (<30 mL/kg). We compared with in-hospital mortality and the rate of discharge to home in two groups. Results: Of 367 patients, 149 received standard fluid resuscitation and 218 received restricted fluid resuscitation. In-hospital mortality was similar in each group (40/149 and 62/218, respectively). Standard fluid resuscitation was not associated with in-hospital mortality (adjusted odds ratio [aOR], 1.05; 95% confidence interval [CI], 0.62-1.77, P = 0.86), but was associated with a significantly lower rate of discharge to home (aOR, 0.55; 95% CI, 0.30-0.98, P = 0.043). There was no significant difference in respiratory rate or need for oxygen therapy post-resuscitation between the two groups. Conclusion: This study suggests that fluid resuscitation may be not beneficial for infected patients with signs of hypoperfusion and a DNI order. Further studies should be conducted on the options for resuscitation management for these patients.

CHARACTERISATION OF RADIOACTIVE CAESIUM IN SEDIMENTS AT THE NOGAWA RIVER, JAPAN.

The TEPCO Fukushima Daiichi Nuclear Power Plant accident that occurred in March 2011 resulted in the release of radioactive caesium into the environment. The radioactive caesium has been detected in the Tama River watershed. Previous investigations have shown that the concentration of radioactive caesium in sediment was relatively high in the Nogawa River. In this study, the relationship between the concentration of radioactive caesium in the sediment and the sediment characteristics was investigated. We found that 137Cs concentration in the tributary sediment has difficulty migrating downstream, while exhibiting a strong correlation with the amount of organic matter and a correlation with the clay, silt layer. Based on the results, we inferred that 137Cs is deposited together with the organic matter and clay, silt layer in the sediment and migrates at a slower pace than that in the mainstem.

Poor prognosis of patients with severe COVID-19 admitted to an infectious disease intensive care unit during the pandemic caused by the Delta variant in Japan.

During the surge of coronavirus disease (COVID-19) caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) delta variant, our institution operated an intensive care unit (ICU) for patients with severe COVID-19. The study aim was to determine the survival rate and treatment outcomes of patients with severe COVID-19 treated in the ICU during the surge. A total of 23 consecutive patients with severe COVID-19 were admitted to the ICU between August 5 and October 6, 2021. Patients received multidrug therapy consisting of remdesivir, tocilizumab, heparin, and methylprednisolone. The patients were divided into two groups based on the ordinal scale (OS): a non-invasive oxygen therapy (OS-6) group, and an invasive oxygen therapy (OS-7) group. There were 13 (57%) and 10 (43%) patients in the OS-7 and OS-6 groups, respectively. All patients were unvaccinated. Sixteen patients (70%) were male. The median age was 53 years; the median body mass index (BMI) was 30.3 kg/m2; and the median P/F ratio on admission was 96. The 30-day survival rate was 69% and was significantly poorer in the OS-7 group (54%) than in the OS-6 group (89%; p = 0.05). The prevalence of obesity (p = 0.05) and the Sequential Organ Failure Assessment (SOFA) score on admission (p < 0.01) were significantly higher in the OS-7 group. Seven patients in the OS-7 group (54%) developed bacteremia. A low P/F ratio on admission was a significant unfavorable prognostic factor (hazard ratio: 10.9; p = 0.03). The survival rate was poor, especially in patients requiring invasive oxygen therapy. More measures are needed to improve the treatment outcomes of patients with severe COVID 19.

Nondestructive discrimination of red silk single fibers using total reflection X-ray fluorescence spectrometry and synchrotron radiation X-ray fluorescence spectrometry.

In a strangulation case, when a necktie is used as a murder weapon, the dyed silk single fiber becomes an important evidence sample to solve the crime. Dyed silk single fibers contain elements, such as Cr and Co, which are obtained from dyeing using metal mordants. Currently, there are no nondestructive and sufficiently sensitive elementary analytical methods for the forensic analysis of single fibers. Therefore, in this study, eight commercially available red silk samples were collected and used for total reflection X-ray fluorescence (TXRF) and synchrotron radiation X-ray fluorescence (SR-XRF) spectrometry. Benchtop TXRF detected both S in the silk protein and Cl and Ca, which are elements absorbed from the environment by silkworms, but also Cr, which is a dyeing derivative for metal mordants. The presence of Cr and Zn, in addition to the Zn/Cr signal intensity ratios, was reported to be particularly useful identifiers. In SR-XRF, the presence of Cr, Co, Zn, and Br and the Zn/Cr signal intensity ratios were reported to be useful discriminating indicators. In this study, the nondestructive discrimination capabilities of TXRF and SR-XRF measurements for the samples were found to be 85.7% and 100%, respectively. Therefore, we propose a combination of TXRF and SR-XRF as a new nondestructive single fiber identification method for forensic science. Moreover, if partial destruction of a single fiber is allowed, the observation of the cross section and micro-Fourier-transform infrared spectroscopy measurements is useful for identifying red silk fibers.

An Evaluation of Total Reflection X-Ray Fluorescence as a Tool for Forensic Discrimination of Single Polyester Fibers.

Total reflection X-ray fluorescence (TXRF) spectrometry was applied to a forensic discrimination of single polyester fibers. In a non-destructive direct measurement of 5 mm long single fibers used for forensic references, trace metallic elements such as Ti, Sb, Ge, Mn, and Co, found in additives and catalyst residues, were detected using a benchtop TXRF spectrometer. The individual elemental compositions of the fibers were identified, and correlations between the compositions and manufacturers were established using principal component analysis (PCA). Black polyester fibers sampled from the car trunk mats were also analyzed. Several fibers were found to contain both Sb and Ge, elements that characterize different polymerization catalysts; this indicates that the fibers were composed of recycled materials. The TXRF and SR-µXRF spectra showed similar patterns for the fiber samples that were analyzed.

SARS-CoV-2 Leakage From the Gas Outlet Port During Extracorporeal Membrane Oxygenation for COVID-19.

Patients with the coronavirus disease 2019 (COVID-19) sometimes develop refractory respiratory failure and may require venovenous extracorporeal membrane oxygenation (VV-ECMO). It is known that the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is sometimes present in the blood of COVID-19 patients. VV-ECMO is often used for several weeks, and plasma leaks can occur, albeit rarely. Hence, in terms of infection control, a concern is that SARS-CoV-2 may leak from the gas outlet port of the oxygenator during ECMO support of critically ill COVID-19 patients. The aim of this study was to clarify whether SARS-CoV-2 leaks from the oxygenator during ECMO support. Five patients with critical COVID-19 pneumonia were placed on VV-ECMO. Silicone-coated polypropylene membrane oxygenators were used in the ECMO circuits for these patients. SARS-CoV-2 ribonucleic acid (RNA) was measured by quantitative reverse transcription polymerase chain reaction in serum and at the gas outlet port of the ECMO circuit at the time of circuit replacement or liberation from ECMO. SARS-CoV-2 RNA was detected in the gas outlet port of the ECMO circuit for three of the five patients. None of the medical staff involved in the care of these five patients has been infected with COVID-19. In conclusion, SARS-CoV-2 could leak to the gas outlet port of the ECMO circuit through silicone-coated polypropylene membranes during ECMO support of critically ill COVID-19 patients.

Extracorporeal membrane oxygenation may decrease the plasma concentration of remdesivir in a patient with severe coronavirus disease 2019.

Remdesivir is an antiviral drug that results in clinical improvement after five days of treatment and accelerates recovery by 31%. No studies have discussed the pharmacokinetic analysis of remdesivir in patients with severe COVID-19 requiring extracorporeal membrane oxygenation (ECMO). A 63-year-old American man who underwent mechanical ventilation and ECMO for severe COVID-19 was administered remdesivir for ten days. The loading dosage was 200 mg at 7 PM on day 12 and 100 mg daily at 0:00 PM from day 13-21, administered within 1 h. The pharmacokinetic analysis was performed. The serum creatinine concentration was within the normal range of 0.5-0.7 mg/dL during treatment. According to the pharmacokinetic analysis, the plasma concentrations of remdesivir and GS-441524 4 h after administration (C4) were 662 ng/mL and 58 ng/mL, respectively, and the concentrations 18 h after administration (C18) were 32 ng/mL and 44 ng/mL, respectively. Therefore, the half-life of remdesivir and GS-441524 was 3.2 and 35.1 h, respectively. Monitoring the plasma concentrations of remdesivir and GS-441524 in patients undergoing ECMO may be necessary.

Derivation of a model to predict mortality in urban patients with accidental hypothermia: a retrospective observational study.

AIM: Accidental hypothermia in urban settings is associated with high mortality rates. However, the predictors of mortality remain under discussion. The purpose of this study was to evaluate prognostic factors and develop a prediction model in patients with accidental hypothermia in urban settings. METHODS: We retrospectively reviewed medical records in patients with hypothermia brought to our hospital by ambulance in a 7-year study period. Patients' records of survival discharge or in-hospital death and clinical data were collected from medical records. We analyzed factors to predict in-hospital death using multiple logistic regression analysis. Recursive partitioning analysis was used to construct a prediction model using predictors from multiple logistic regression analysis. RESULTS: In the study period, 192 patients were included in this study. Of them, 154 patients were discharged alive and 38 patients died. Multiple logistic regression analysis revealed that in-hospital death was related to Glasgow Coma Scale (GCS) score, prothrombin time - international normalized ratio (PT-INR) value, and fibrin degradation product (FDP). Recursive partitioning analysis revealed that patients with accidental hypothermia could be divided into four groups: very high risk (FDP ≥ 14 µg/mL, PT-INR ≥ 1.4), high risk (FDP ≥ 14 µg/mL, PT-INR < 1.4), moderate risk (FDP < 14 µg/mL, GCS < 10), and low risk (FDP < 14 µg/mL, GCS ≥ 10). CONCLUSION: High FDP and PT-INR values and low GCS score on arrival at the emergency department were associated with in-hospital mortality in urban patients with hypothermia. A simple prediction model for grouping risk was developed using these predictors.

Impact of frailty on protocol-based weaning from mechanical ventilation in patients with sepsis: a retrospective cohort study.

AIM: Frailty has been shown to be associated with prolonged mechanical ventilation (MV). However, due to limited physiological data, it has been unclear how frailty affects weaning from MV in septic patients subjected to a specific weaning protocol. METHODS: This was a single-center retrospective cohort study. The study included patients with sepsis on MV who underwent protocol-based weaning between August 2015 and December 2018. Frailty was defined as a Clinical Frailty Scale score 4 or more. The association between frailty and weaning was evaluated. RESULTS: Ninety-nine eligible patients were identified and categorized as frail (n = 67) or not frail (n = 32). The duration of MV was significantly longer in the frail group (8 days versus 5 days, P < 0.01). In multivariate analysis, frailty was independently associated with duration of MV (regression coefficient 17.97, 95% confidence interval 1.77-34.17) and successful weaning (hazard ratio 0.60, 95% confidence interval 0.36-1.00). There was no significant between-group difference in duration until the first separation attempt or reintubation rate. Respiratory failure was significantly more common in the frail group as a cause of weaning failure, whereas airway failure was common in both groups. CONCLUSION: Frailty was independently associated with a longer duration of MV in patients with sepsis who underwent protocol-based weaning. Frail patients were more likely to fail spontaneous breathing trials than nonfrail patients during the weaning process, although the risk after extubation was similar.