Risk factors for recurrence of suicide attempt via overdose: A prospective observational study.

BACKGROUND: Although the prevalence of drug overdose has gradually increased worldwide, the risk factors associated with the recurrence of suicide attempts via drug overdose have not been well elucidated. In this study, we investigated the clinical course of patients with drug overdose and whether or not patients reattempted suicide via overdose, using telephone interviews, to evaluate the risk factors associated with overdose recurrence. METHODS: This prospective observational study enrolled patients who attempted suicide by drug overdose and were transferred to a tertiary emergency hospital in Japan between January 1, 2015 and July 30, 2021. Recurrence of overdose within 1 year of admission for overdose was designated as the primary outcome. Multivariable logistic regression analysis was performed to assess the independent risk factors for the recurrence of overdose. Furthermore, we compared the difference in the recurrence interval between patients with and without cohabitants using the log-rank test. RESULTS: A total of 94 patients were identified, and recurrence of overdose was observed in 28 patients (29.8%). The median recurrence interval was 6.0 months [IQR (interquartile range), 4.0-7.0 months]. The recurrence rate was significantly higher in patients with a history of schizophrenia than that in patients without a history of schizophrenia (58.3% vs 25.6%, p = 0.048), and significantly lower in patients with cohabitants than that in patients without cohabitants (22.6% vs 43.8%, p = 0.015). The presence of a cohabitant was significantly associated with a longer recurrence interval (p = 0.049). The effect of psychiatric intervention during hospitalization and psychiatric visits after discharge could not be found in this study. CONCLUSIONS: A history of schizophrenia was an independent risk factor for the recurrence of overdose, and the presence of a cohabitant was significantly associated with a lower risk of recurrence. Large-scale, long-term studies are required to confirm the results of this study.

Subchronic tolerance trials of graded oral supplementation with ornithine hydrochloride or citrulline in healthy adults.

Ornithine and citrulline are amino acids used in dietary supplements and nutritional products consumed by healthy consumers, but the safe supplementation levels of these compounds are unknown. The objective of this study was to conduct two 4-week clinical trials to evaluate the safety and tolerability of graded dosages of oral ornithine (as hydrochloride) and citrulline. Healthy male adults (n = 60, age 41.4 ± 1.5 years) completed graded dosages of either ornithine hydrochloride (3.2, 6, 9.2, and 12 g/day) or citrulline (6, 12, 18, and 24 g/day) supplement for 4 weeks with 2-week wash-out periods in between. Primary outcomes included vitals, a broad spectrum of circulating biochemical analytes, body weight, sleep quality, and mental self-assessment. In the ornithine hydrochloride supplementation group, minor increase in plasma aspartic acid and glutamic acid concentrations was observed at the highest intake dosages. In the citrulline supplementation group, minor changes in laboratory data for serum lactate dehydrogenase and plasma amino acid concentration of lysine, methionine, threonine, aspartic acid, glutamic acid, glutamine and ornithine, arginine, and citrulline itself were measured. No other changes in measured parameters were observed, and study subjects tolerated 4-week-long oral supplementation of ornithine hydrochloride or citrulline without treatment-related adverse events. A clinical, no-observed-adverse-effect-level (NOAEL) of ornithine hydrochloride and citrulline supplementation in healthy adult males was determined to be 12 g/day and 24 g/day (4 weeks), respectively.

Tourniquet self-application assessment in cold weather conditions.

BACKGROUND: Our study aimed to assess the ability of nonmedical civilians to self-apply extremity tourniquets in cold weather conditions while wearing insulating technical clothing after receiving basic training. METHODS: A field study was conducted among 37 voluntary participants of an expedition party to the Spanish Antarctic base. The researchers assessed the participant's ability to self-apply five commercial extremity tourniquets (CAT, OMNA, RMT, SWAT-T, and RATS) over cold-weather clothing and their achieved effectiveness for vascular occlusion. Upper extremity self-application was performed with a single-handed technique (OHT), and lower extremity applying a two-handed technique (THT). Perceptions of self-application ease mean values ± standard deviation (SD) were compared by applying a 5% statistical significance threshold. Frequency count determined tourniquet preference. RESULTS: All the tested ETs, except the SWAT-T, were properly self-applied with an OHT, resulting in effective vascular occlusion in the upper extremity. The five devices tested were self-applied correctly in the lower extremities using THT. The ratcheting marine-designed OMNA ranked the highest for application easiness on both the upper and lower extremities, and the windlass CAT model was the preferred device by most participants. CONCLUSIONS: Civilian extremity tourniquet self-application on both upper and lower extremities can be accomplished in cold weather conditions despite using cold-weather gloves and technical clothing after receiving brief training. The ratcheting marine-designed OMNA ranked the highest for application ease, and the windlass CAT model was the preferred device.

Dielectric Blood Coagulometry for the Early Detection of Sepsis-Induced Disseminated Intravascular Coagulation: A Prospective Observational Study.

OBJECTIVES: To evaluate the utility of dielectric blood coagulometry for early sepsis-induced disseminated intravascular coagulation diagnosis. DESIGN: Single-center, prospective observational study. SETTING: Patients with sepsis or septic shock at the Tokyo Medical and Dental University Hospital of Medicine between September 2019 and September 2020. PATIENTS: The patients were divided into three groups according to the timing of disseminated intravascular coagulation diagnosis based on the Disseminated Intravascular Coagulation score by the Japanese Association for Acute Medicine: 1) no disseminated intravascular coagulation group, 2) late-diagnosed disseminated intravascular coagulation group: not diagnosed with disseminated intravascular coagulation on day 1 but diagnosed within 48 hours after admission, and 3) disseminated intravascular coagulation group: diagnosed with disseminated intravascular coagulation on day 1. The study evaluated 80 patients (no disseminated intravascular coagulation, 31 [38.8%]; late-diagnosed disseminated intravascular coagulation, 34 (42.5%); disseminated intravascular coagulation, 15 [18.8%]). MEASUREMENTS AND MAIN RESULTS: We compared the clinical severity scores and mortality of the groups and assessed the correlation between the dielectric blood coagulometry-derived coagulation marker, thrombin levels, and Disseminated Intravascular Coagulation score using Spearman rank correlation. The mortality rate was 0% (0/31) in the no disseminated intravascular coagulation group, 35.3% (12/34) in the late-diagnosed disseminated intravascular coagulation group, and 33.3% (5/15) in the disseminated intravascular coagulation group. Although the Disseminated Intravascular Coagulation score on day 1 did not reflect disseminated intravascular coagulation in approximately 70% of patients who developed disseminated intravascular coagulation by day 2, dielectric clot strength measured by dielectric blood coagulometry on day 1 strongly correlated with disseminated intravascular coagulation development by day 2 (Spearman ρ = 0.824; p < 0.05) and with thrombin level on day 1 (Spearman ρ = 0.844; p < 0.05). CONCLUSIONS: Dielectric blood coagulometry can be used to detect early-phase disseminated intravascular coagulation in patients with sepsis and is strongly correlated with thrombin levels. Larger studies are needed to verify our results for developing clinical applications.

Motivating factors for frontline healthcare workers during the COVID-19 pandemic: A survey in Japan.

Healthcare workers (HCWs), who are at the frontline of the COVID-19 pandemic, treated COVID-19 patients under many types of stress for over a year. As an external motivating factor, incentives could be important for HCWs dealing with COVID-19. However, there has been no research regarding the change in the consciousness of HCWs during the unrelenting waves of COVID-19. Therefore, we conducted a survey of HCWs during different waves of COVID-19 (the second and fourth waves in Japan). An open web-based survey was conducted among HCWs who wore PPE while treating COVID-19 patients. The first survey of HCWs in Japan was conducted from August 27 to September 9, 2020, while the second survey was conducted from April 7 to May 10, 2021, during the second and fourth waves, respectively. The first and second surveys had 157 and 125 participants, respectively. There were no significant differences in the characteristics of the participants in the first and second survey groups regarding the types of occupation, age, sex, or full-time status. The percentage of HCWs who required financial incentives to maintain motivation remained high (88.5% vs. 82.7%). In addition, most frontline HCWs hope for regular SARS-CoV-2 PCR testing, which will be provided free of charge, as a necessary incentive. External motivating factors, such as financial and other incentives, were important to maintain the motivation of HCWs during the second and fourth waves of the COVID-19 pandemic in Japan. Supplementary Information: The online version contains supplementary material available at 10.1007/s12144-022-04177-6.

Derivation and validation of an easy-to-compute trauma score that improves prognostication of mortality or the Trauma Rating Index in Age, Glasgow Coma Scale, Respiratory rate and Systolic blood pressure (TRIAGES) score.

BACKGROUND: Multiple trauma scores have been developed and validated, including the Revised Trauma Score (RTS) and the Mechanism, Glasgow Coma Scale, Age, and Arterial Pressure (MGAP) score. However, these scores are complex to calculate or have low prognostic abilities for trauma mortality. Therefore, we aimed to develop and validate a trauma score that is easier to calculate and more accurate than the RTS and the MGAP score. METHODS: The study was a retrospective prognostic study. Data from patients registered in the Japan Trauma Databank (JTDB) were dichotomized into derivation and validation cohorts. Patients' data from the Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage-2 (CRASH-2) trial were assigned to another validation cohort. We obtained age and physiological variables at baseline, created ordinal variables from continuous variables, and defined integer weighting coefficients. Score performance to predict all-cause in-hospital death was assessed using the area under the curve in receiver operating characteristics (AUROC) analyses. RESULTS: Based on the JTDB derivation cohort (n = 99,867 with 12.5% mortality), the novel score ranged from 0 to 14 points, including 0-2 points for age, 0-6 points for the Glasgow Coma Scale, 0-4 points for systolic blood pressure, and 0-2 points for respiratory rate. The AUROC of the novel score was 0.932 for the JTDB validation cohort (n = 76,762 with 10.1% mortality) and 0.814 for the CRASH-2 cohort (n = 19,740 with 14.6% mortality), which was superior to RTS (0.907 and 0.808, respectively) and MGAP score (0.918 and 0.774, respectively) results. CONCLUSIONS: We report an easy-to-use trauma score with better prognostication ability for in-hospital mortality compared to the RTS and MGAP score. Further studies to test clinical applicability of the novel score are warranted.

Neuroenteric axis modulates the balance of regulatory T cells and T-helper 17 cells in the mesenteric lymph node following trauma/hemorrhagic shock.

CD103(+) dendritic cells (DCs) continuously migrate from the intestine to the mesenteric lymph nodes (MLNs) and maintain tolerance by driving the development of regulatory T cells (Treg) in the gut. The relative expression of Treg and T-helper 17 (Th17) cells determines the balance between tolerance and immunity in the gut. We hypothesized that trauma/hemorrhagic shock (T/HS) would decrease the CD103(+) DC population in the mesenteric lymph and alter the Treg-to-Th17 ratio in the MLN. We further hypothesized that vagus nerve stimulation (VNS) would promote tolerance to inflammation by increasing the Treg-to-Th17 ratio in the MLN after injury. Male rats were assigned to sham shock (SS), trauma/sham shock (T/SS), or T/HS. T/HS was induced by laparotomy and 60 min of HS (blood pressure 35 mmHg) followed by fluid resuscitation. A separate cohort of animals underwent cervical VNS after the HS phase. MLN samples were collected 24 h after resuscitation. The CD103(+) DC population and Treg-to-Th17 cell ratio in the MLN were decreased after T/HS compared with SS and T/SS, suggesting a shift to an inflammatory response. VNS prevented the T/HS-induced decrease in the CD103(+) DC population and increased the Treg-to-Th17 ratio compared with T/HS alone. VNS alters the gut inflammatory response to injury by modulating the Treg-Th17 cell balance in the MLN. VNS promotes tolerance to inflammation in the gut, further supporting its ability to modulate the inflammatory set point and alter the response to injury.

L-Citrulline dilates rat retinal arterioles via nitric oxide- and prostaglandin-dependent pathways in vivo.

L-Citrulline is an effective precursor of L-arginine produced by the L-citrulline/L-arginine cycle, and it exerts beneficial effects on the cardiovascular system by supporting enhanced nitric oxide (NO) production. NO dilates retinal blood vessels via the cyclooxygenase-mediated pathway. The purpose of this study was to examine the effects of L-citrulline on retinal circulation and to investigate the potential involvement of NO and prostaglandins in L-citrulline-induced responses in rats. L-Citrulline (10-300 µg kg(-1) min(-1), i.v.) increased the diameter of retinal arterioles without significantly changing mean blood pressure, heart rate, and fundus blood flow. The vasodilator response of retinal arterioles to l-citrulline was significantly diminished following treatment with N(G)-nitro-L-arginine methyl ester (30 mg/kg, i.v.), an NO synthase inhibitor, or indomethacin (5 mg/kg, i.v.), a cyclooxygenase inhibitor. In addition, α-methyl-dl-aspartic acid (147 mg/kg, i.v.), an inhibitor of argininosuccinate synthase, the rate-limiting enzyme for the recycling of l-citrulline to l-arginine, diminished the L-citrulline-induced retinal vasodilation. These results suggest that both NO- and prostaglandin-dependent pathways contribute to the L-citrulline-induced vasodilation of rat retinal arterioles. The L-citrulline/L-arginine recycling pathway may have more importance in regulating vascular tone in retinal blood vessels than in peripheral resistance vessels.

The vagus nerve alters the pulmonary dendritic cell response to injury.

BACKGROUND: We have shown previously that vagal nerve stimulation (VNS) protects against burn-induced acute lung injury (ALI). Although the mobilization and activation of immune cells is central to tissue injury caused by the systemic inflammatory response, the specific inflammatory cell populations that are modulated by VNS have yet to be fully defined. The purpose of this study was to assess whether VNS alters inflammatory cell recruitment to the lung after severe burn injury. MATERIALS AND METHODS: Male C57BL/6 mice were subjected to 30% total body surface area steam burn with and without electrical stimulation of the right cervical vagus nerve. The relative levels of pulmonary dendritic cells (DC) and macrophages were compared at 4 h versus 24 h after burn injury. Lung tissue injury was characterized by histology to assess changes in lung architecture, and measure the protein levels of interleukin 6 and transforming growth factor-ß1. RESULTS: Severe burn caused an increase in pulmonary DC recruitment at 4 h after injury that persisted at 24 h after severe burn, whereas there was no change in the number of pulmonary macrophages. In contrast, VNS limited the burn-induced recruitment of pulmonary DC. VNS prevented histologic lung injury and attenuated the release of interleukin 6 and transforming growth factor-ß1 in the lung after burn injury. CONCLUSIONS: VNS is an effective method to limit pulmonary DC recruitment to the lung and prevent ALI after burn injury. Identifying strategies to limit inflammatory cell recruitment to the lung may have clinical utility in preventing ALI in severely burned patients.

Low-dose vitamin K2 (MK-4) supplementation for 12 months improves bone metabolism and prevents forearm bone loss in postmenopausal Japanese women.

Menaquinone-4 (MK-4) administered at a pharmacological dosage of 45 mg/day has been used for the treatment of osteoporosis in Japan. However, it is not known whether a lower dose of MK-4 supplementation is beneficial for bone health in healthy postmenopausal women. The aim of this study was to examine the long-term effects of 1.5-mg daily supplementation of MK-4 on the various markers of bone turnover and bone mineral density (BMD). The study was performed as a randomized, double-blind, placebo-controlled trial. The participants (aged 50-65 years) were randomly assigned to one of two groups according to the MK-4 dose received: the placebo-control group (n = 24) and the 1.5-mg MK-4 group (n = 24). The baseline concentrations of undercarboxylated osteocalcin (ucOC) were high in both groups (>5.1 ng/ml). After 6 and 12 months, the serum ucOC concentrations were significantly lower in the MK-4 group than in the control group. In the control group, there was no significant change in serum pentosidine concentrations. However, in the MK-4 group, the concentration of pentosidine at 6 and 12 months was significantly lower than that at baseline. The forearm BMD was significantly lower after 12 months than at 6 months in the control group. However, there was no significant decrease in BMD in the MK-4 group during the study period. These results suggest that low-dose MK-4 supplementation for 6-12 months improved bone quality in the postmenopausal Japanese women by decreasing the serum ucOC and pentosidine concentrations, without any substantial adverse effects.

Randomised controlled trial of the effects of L-ornithine on stress markers and sleep quality in healthy workers.

BACKGROUND: L-ornithine is a non-essential, non-protein amino acid. Although L-ornithine is contained in various foods, the amount is usually small.Recently, studies have shown that orally administered L-ornithine reduced the stress response in animals.From these findings, we speculated that L-ornithine may play a role in the relieve of stress and improve sleep and fatigue symptoms in humans. Through a randomised, double-blind, placebo-controlled clinical study, we asked if L-ornithine could be beneficial to stress and sleep in healthy workers. METHOD: Fifty-two apparently healthy Japanese adults who had previously felt slight stress as well as fatigue were recruited to be study participants and were randomly divided into either the L-ornithine (400 mg/day) or placebo group. They orally consumed the respective test substance every day for 8 weeks. Serum was collected for the assessment of cortisol and dehydroepiandrosterone-sulphate (DHEA-S). Perceived mood and quality of sleep were measured by the Profile of Mood States (POMS), Athens Insomnia Scale (AIS), and Ogri-Shirakawa-Azumi sleep inventory MA version (OSA-MA). RESULTS: Serum cortisol levels and the cortisol/DHEA-S ratio were significantly decreased in the L-ornithine group in comparison with the placebo group. Also, anger was reduced and perceived sleep quality was improved in the L-ornithine group. CONCLUSION: L-ornithine supplementation has the potential to relieve stress and improve sleep quality related to fatigue, both objectively and subjectively.

Successful Management With Continuous Negative Abdominal Pressure Therapy in a Severely Obese Patient With Inhalation Burn-Induced Severe Respiratory Failure Requiring Veno-Venous Extracorporeal Membrane Oxygenation: A Case Report.

Continuous negative abdominal pressure (CNAP) therapy effectively provides respiratory support in patients with respiratory failure and severe obesity; however, its use in clinical practice remains limited. In this case, we report a significant improvement in the respiratory condition of a patient with severe obesity and inhalation burns following the application of CNAP in addition to venovenous extracorporeal membrane oxygenation (V-V ECMO) and mechanical ventilation. The patient was able to wean off these devices successfully. This case highlights the potential of CNAP therapy as an adjunct treatment for severe respiratory failure, particularly in obese patients for whom conventional interventions are insufficient.

Effect of Early Cyclosporine Treatment on Survival in Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis.

INTRODUCTION: Early cyclosporine administration is a potentially useful treatment in patients with Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN). However, previous studies have reported conflicting results regarding the survival benefits. Therefore, in this study, we evaluated the survival of patients with SJS/TEN according to whether they received early cyclosporine administration. METHODS: This retrospective cohort study was conducted using a Japanese national administrative claims database. Data on patients admitted to the hospital with SJS/TEN between April 1, 2016, and March 31, 2021, were extracted. Patients with missing data, those discharged within two days of admission, pregnant women, and children aged <16 years were excluded. Patients who received cyclosporine on the day of admission (early cyclosporine group) were compared with those who did not (comparison group). The primary endpoint was in-hospital mortality. Secondary endpoints were 30- and 50-day mortality and length of hospital stay. The effect of early cyclosporine treatment was evaluated after baseline adjustment using doubly robust estimation. RESULTS: Among 3807 enrolled patients (mean age, 65.5 years; 53.8% women), the early cyclosporine and comparison groups included 115 and 3692 patients, respectively. After adjustment, cyclosporine treatment decreased in-hospital mortality by 6.03% (95% confidence interval (CI), 5.27-6.82%), 30-day mortality by 2.94% (95% CI, 2.43-3.50%), and 50-day mortality by 4.38% (95% CI, 3.70-5.04%), but increased the length of hospital stay by 9.45 days (95% CI, 1.00-20.23 days). CONCLUSION: Early cyclosporine administration can improve the survival of patients with SJS/TEN but is associated with a longer hospital stay.

Gastric rupture caused by intragastric perforation of splenic artery aneurysm: a case report and literature review.

BACKGROUND: The rupture of splenic artery pseudoaneurysm (SAP) is life-threatening disease, often caused by trauma and pancreatitis. SAPs often rupture into the abdominal cavity and rarely into the stomach. CASE PRESENTATION: A 70-year-old male with no previous medical history was transported to our emergency center with transient loss of consciousness and tarry stools. After admission, the patient become hemodynamically unstable and his upper abdomen became markedly distended. Contrast-enhanced computed tomography performed on admission showed the presence of a splenic artery aneurysm (SAP) at the bottom of a gastric ulcer. Based on the clinical picture and evidence on explorative tests, we established a preliminary diagnosis of ruptured SAP bleeding into the stomach and performed emergency laparotomy. Intraoperative findings revealed the presence of a large intra-abdominal hematoma that had ruptured into the stomach. When we performed gastrotomy at the anterior wall of the stomach from the ruptured area, we found pulsatile bleeding from the exposed SAP; therefore, the SAP was ligated from inside of the stomach, with gauze packing into the ulcer. We temporarily closed the stomach wall and performed open abdomen management, as a damage control surgery (DCS) approach. On the third day of admission, total gastrectomy and splenectomy were performed, and reconstruction surgery was performed the next day. Histopathological studies of the stomach samples indicated the presence of moderately differentiated tubular adenocarcinoma. Since no malignant cells were found at the rupture site, we concluded that the gastric rupture was caused by increased internal pressure due to the intra-abdominal hematoma. CONCLUSIONS: We successfully treated a patient with intragastric rupture of the SAP that was caused by gastric cancer invasion, accompanied by gastric rupture, by performing DCS. When treating gastric bleeding, such rare causes must be considered and appropriate diagnostic and therapeutic strategies should be designed according to the cause of bleeding.

Use of resuscitative endovascular balloon occlusion of the aorta (REBOA) for trauma and its performance in Japan over the past 18 years: a nationwide descriptive study.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been used to control massive hemorrhages. Although there is no consensus on the efficacy of REBOA, it remains an option as a bridging therapy in non-trauma centers where trauma surgeons are not available. To better understand the current landscape of REBOA application, we examined changes in its usage, target population, and treatment outcomes in Japan, where immediate hemostasis procedures sometimes cannot be performed. METHODS: This retrospective observational study used the Japan Trauma Data Bank data. All cases in which REBOA was performed between January 2004 and December 2021 were included. The primary outcome was the in-hospital mortality rate. We analyzed mortality trends over time according to the number of cases, number of centers, severity of injury, and overall and subgroup mortality associated with REBOA usage. We performed a logistic analysis of mortality trends over time, adjusting for probability of survival based on the trauma and injury severity score. RESULTS: Overall, 2557 patients were treated with REBOA and were deemed eligible for inclusion. The median age of the participants was 55 years, and male patients constituted 65.3% of the study population. Blunt trauma accounted for approximately 93.0% of the cases. The number of cases and facilities that used REBOA increased until 2019. While the injury severity score and revised trauma score did not change throughout the observation period, the hospital mortality rate decreased from 91.3 to 50.9%. The REBOA group without severe head or spine injuries showed greater improvement in mortality than the all-patient group using REBOA and all-trauma patient group. The greatest improvement in mortality was observed in patients with systolic blood pressure ≥ 80 mmHg. The adjusted odds ratios for hospital mortality steadily declined, even after adjusting for the probability of survival. CONCLUSIONS: While there was no significant change in patient severity, mortality of patients treated with REBOA decreased over time. Further research is required to determine the reasons for these improvements in trauma care.

Does frailty impact failure-to-rescue in geriatric trauma patients?

BACKGROUND: Failure-to-rescue (FTR), defined as death following a major complication, is a metric of trauma quality. The impact of patient frailty on FTR has not been fully investigated, especially in geriatric trauma patients. This study hypothesized that frailty increased the risk of FTR in geriatric patients with severe injury. METHODS: A retrospective cohort study was conducted using the TQIP database between 2015 and 2019, including geriatric patients with trauma (age ≥65 years) and an Injury Severity Score (ISS) > 15, who survived ≥48 hours postadmission. Frailty was assessed using the modified 5-item frailty index (mFI). Patients were categorized into frail (mFI ≥ 2) and nonfrail (mFI < 2) groups. Logistic regression analysis and a generalized additive model (GAM) were used to examine the association between FTR and patient frailty after controlling for age, sex, type of injury, trauma center level, ISS, and vital signs on admission. RESULTS: Among 52,312 geriatric trauma patients, 34.6% were frail (mean mFI: frail: 2.3 vs. nonfrail: 0.9, p < 0.001). Frail patients were older (age, 77 vs. 74 years, p < 0.001), had a lower ISS (19 vs. 21, p < 0.001), and had a higher incidence of FTR compared with nonfrail patients (8.7% vs. 8.0%, p = 0.006). Logistic regression analysis revealed that frailty was an independent predictor of FTR (odds ratio, 1.32; confidence interval, 1.23-1.44; p < 0.001). The GAM plots showed a linear increase in FTR incidence with increasing mFI after adjusting for confounders. CONCLUSION: This study demonstrated that frailty independently contributes to an increased risk of FTR in geriatric trauma patients. The impact of patient frailty should be considered when using FTR to measure the quality of trauma care. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Analysis of lipid metabolites derived from gut microbiota in ischemia-reperfusion model.

BACKGROUND: Disruption of intestinal barrier caused by intestinal ischemia due to hemorrhagic shock is associated with the pathogenesis of multiple organ dysfunction (MOD) after severe trauma. Mesenteric lymph (ML) plays an important role as a route for transporting inflammatory mediators, including lipids. Postbiotics, such as 10-hydroxy-cis-12-octadecenoic acid (HYA), have received much attention as a treatment option. However, the relationship between postbiotics and MOD has yet to be clarified. The aim of the present study was to analyze lipid metabolites derived from gut microbiota in the intestinal ischemia-reperfusion (IR) rat model. METHODS: Male Sprague-Dawley rats underwent laparotomy, and their ML duct and superior mesenteric artery were exposed. The superior mesenteric artery was clamped for 60 minutes, followed by 120 minutes of reperfusion. The ML and the plasma were collected before and after intestinal IR. Lipids were extracted from plasma and ML, and liquid chromatography-tandem mass spectrometry was performed. RESULTS: The concentration of linoleic acid in plasma samples was not different before and after IR; however, the linoleic acid concentration in the ML samples increased after intestinal IR. Eicosapentaenoic acids and docosahexaenoic related to linoleic acids showed similar changes with IR-induced increase in the ML. The concentration of HYA, a linoleic acid-derived bioactive metabolite produced by gut bacteria, was high in ML samples, while that in plasma samples was low. The relative increase rate of HYA in ML samples after IR was higher than that of the plasma samples (the ML samples: relative increase, 3.23 ± 1.36; the plasma samples: relative increase, 0.95 ± 0.35; n = 3, p = 0.048). CONCLUSION: The present study demonstrated increased linoleic acids and high concentrations of HYA, lipid metabolites derived from gut bacteria in the ML after intestinal IR. These findings may contribute to clarifying the relation between gut microbiota and MOD after severe trauma.

A well-managed case of discontinuous anorectal injury caused by a personal watercraft treated by combining surgery and colonoscopy.

Background: Anorectal injury caused by personal watercraft (PWC)-related trauma is rare. However, PWC accidents have increased recently, and since patients tend to be younger, treatment strategies should consider anal function preservation in addition to saving lives. Case Presentation: A 30-year-old female patient who fell into the water when a PWC suddenly accelerated and injured her perineum with a forceful water jet was transported to our hospital. On examination, she was diagnosed with a traumatic rectal perforation with intraperitoneal findings and an anorectal injury. Emergency surgery, which involved direct suturing, temporary colostomy with intraoperative endoscopy for the rectal perforation, and anorectal reconstruction, was performed. The patient was discharged on postoperative day 19 without complications, and the colostomy was closed 5 months postoperatively. Conclusion: We encountered a case of multiple noncontinuous anorectal injuries due to a PWC accident that was successfully treated using a combination of surgery and intraoperative endoscopy.

Prostaglandin E-major urinary metabolites as a new biomarker for acute mesenteric ischemia.

BACKGROUND: Acute mesenteric ischemia (AMI) is an emergent vascular disease caused by cessation of the blood supply to the small intestine. Despite advances in the diagnosis, intervention, and surgical procedures, AMI remains a life-threatening condition. Prostaglandin E2 major urinary metabolite (PGE-MUM), the urinary metabolite of prostaglandin E2, is known to be stable in urine and has been suggested to be a valuable biomarker for intestinal mucosal inflammation, such as ulcerative colitis. We therefore investigated whether or not PGE-MUM levels reflect the degree of ischemia in an intestinal ischemia-reperfusion model. METHODS: Male rats were used to establish a superior mesenteric artery occlusion (SMAO) group, in which the superior mesenteric artery was clamped, and a sham group. The clamping times in the SMAO group were either 30 minutes or 60 minutes, and reperfusion times were either 3 hours or 6 hours, after which PGE-MUM values were measured. RESULTS: The histological injury score of the SMAO (30-minute ischemia and 6-hour reperfusion group, 1.8 ± 0.4; 60-minute ischemia and 6-hour reperfusion group, 4.7 ± 0.5) and were significantly greater than that of the sham group (0.4 ± 0.7, p < 0.05). The PGE-MUM levels in the SMAO group (30-minutes ischemia and 6-hour reperfusion group, 483 ± 256; 60-minutes ischemia and 6-hour reperfusion group, 889 ± 402 ng/mL) were significantly higher than in the sham group (30-minute and 6-hour observation group, 51 ± 20; 60-minute and 6-hour observation group, 73 ± 32 ng/mL; p < 0.05). Furthermore, the PGE-MUM value was corrected by the concentration of urinary creatinine (Cr). The PGE-MUM/urinary Cr levels in the SMAO group were also significantly higher than in the sham group ( p < 0.05). CONCLUSION: We found that intestinal ischemia-reperfusion increased urinary PGE-MUM levels depending on the ischemic time. This suggests the potential utility of PGE-MUM as a noninvasive marker of intestinal ischemia.