Procalcitonin levels predict to identify bacterial strains in blood cultures of septic patients.

BACKGROUND: We examined whether the values obtained from principal component analysis (PCA) on laboratory tests can be used to predict bacterial infections and identify bacterial strains in blood culture (BC). METHOD: This study is a single-center retrospective analysis of 315 patients suspected of having sepsis. We applied PCA on procalcitonin (PCT) and laboratory test biomarkers, namely, platelet (PLT), white blood cell, and C-reactive protein (CRP) as well as BC. RESULTS: Principal component analysis showed that PCT, CRP, and PLT contributions to component 1 were associated with bacterial infection. The number of patients who had BC-negative results, gram-positive cocci (GPC), and gram-negative rods (GNRs) were 124, 28, and 19, respectively. The mean value of component 1 in GNR-positive patients was 1.58±1.41 and was significantly higher than that in GPC-positive patients (0.28±0.87; P<.0001). Furthermore, the mean values of component 1 in both GNR- and GPC-positive patients were significantly higher than that in BC-negative patients (-0.31±0.65; P<.0001 and P<.002, respectively). One certain range showing higher value more than 2.00 for component 1 and -1.00 for component 2 only included GNR-positive patients. There were no BC-positive patients who showed less than -1.00 for component 1. CONCLUSION: The present results obtained by PCA on laboratory tests involving PCT, PLT, white blood cell, and CRP suggest the potential of PCA-obtained values to not only predict bloodstream infection but also identify bacterial strains. This provides some clinical significance in the management of sepsis in acute care.

Evidence-based Effective Triage Operation During Disaster: Application of Human-trajectory Data to Triage Drill Sessions.

INTRODUCTION: Though many governmental and nongovernmental efforts for disaster prevention have been sought throughout Japan since the Great East Japan Earthquake on March 11, 2011, most of the preparation efforts for disasters have been based more on structural and conventionalized regulations than on scientific and objective grounds. Problem There has been a lack of scientific knowledge for space utilization for triage posts in disaster drill sessions. This report addresses how participants occupy and make use of the space within a triage post in terms of areas of use and occupied time. METHOD: The trajectories of human movement by using Ubiquitous Stereo Vision (USV) cameras during two emergency drill sessions held in 2012 in a large commercial building have been measured. The USV cameras collect each participant's travel distance and the wait time before, during, and after undergoing triage. The correlation between the wait time and the space utilization of patients at a triage post has been analyzed. RESULTS: In the first session, there were some spaces not entirely used. This was caused largely by a patient who arrived earlier than others and lingered in the middle area, which caused the later arrivals to crowd the entrance area. On the other hand, in the second session, the area was used in a more evenly-distributed manner. This is mainly because the earlier arrivals were guided to the back space of the triage post (ie, the opposite side of the entrance), and the late arrivals were also guided to the front half, which was not occupied by anyone. As a result, the entire space was effectively utilized without crowding the entrance. CONCLUSION: This study has shown that this system could measure people's arrival times and the speed of their movements at the triage post, as well as where they are placed until they receive triage. Space utilization can be improved by efficiently planning and controlling the positioning of arriving patients. Based on the results, it has been suggested that for triage operation, it is necessary to efficiently plan and control the placement of patients in order to use strategically limited spatial resources.

Prediction of blood culture results by measuring procalcitonin levels and other inflammatory biomarkers.

BACKGROUND: It would be helpful if we could predict positive or negative blood culture results. This study considered the usefulness of measuring procalcitonin (PCT) level and standard clinical biomarkers such as white blood cell (WBC) count, C-reactive protein (CRP) level, and platelet (PLT) count to predict blood culture results. METHOD: We retrospectively analyzed the data from 422 specimens collected at our emergency center within the preceding 36 consecutive months. Primary component analysis (PCA) was used for detecting the degree of the relational contribution of each of the 4 biomarkers to the blood culture results. RESULTS: Procalcitonin alone (cut-off value, 0.5 ng/mL) yielded a positive blood culture rate of 34.0%. Procalcitonin plus 3 biomarkers (WBC, CRP, and PLT) analyzed by PCA yielded 45.9% or 35.3% when a case was in the first or fourth quadrant, which was significantly higher than cases in the second or third quadrant. Primary component analysis also revealed that positive blood culture results were mainly affected by primary component 1, to which PCT and PLT (not WBC or CRP) predominantly contribute. CONCLUSION: Although it is difficult to predict blood culture results, even using 4 biomarkers analyzed by PCA, our new finding that blood culture results are affected not by WBC and CRP, but mainly by PCT and PLT, might help explain the mechanism of sepsis.

Clinical efficacy and safety of arbekacin sulfate in patients with MRSA sepsis or pneumonia: a multi-institutional study.

Arbekacin (ABK) is an aminoglycoside and widely used in Japan for treatment of patients infected with methicillin-resistant Staphylococcus aureus (MRSA). Although, ABK has concentration-dependent antibacterial activity, the peak serum concentration (C (peak)) of ABK has not yet been fully investigated as an indicator of the efficacy of ABK. The present study was conducted in patients admitted to hospitals affiliated with the ABK Dose Finding Study Group, between October 2008 and June 2011, who had pneumonia or sepsis, the cause of which was identified or suspected to be MRSA. The initial target C (peak) was set at 15-20 µg/mL and therapeutic drug monitoring was conducted. Then the relationship between serum concentration and efficacy/safety of ABK was prospectively examined to obtain sufficient clinical efficacy. In total, 89 patients from 11 clinical sites in Japan were enrolled and 29 of these patients were subjected to efficacy analysis. The mean initial dose and C (peak) were 306.9 mg/day and 16.2 µg/mL, respectively. The efficacy rate was 95 % (19/20 patients) at 5-6 mg/kg or higher, 87.5 % (7/8) for sepsis and 90.5 % (19/21) for pneumonia, and the overall efficacy rate was 89.7 % (26/29). There was no increase in the incidence of adverse events. In conclusion, we recommend the initial dose of ABK at 5-6 mg/kg or higher and the dosage regimen should be adjusted to achieve C (peak) at 10-15 µg/mL or higher in the treatment of patients with pneumonia or sepsis caused by MRSA. This strategy would surely achieve low incidence of adverse events while obtaining high clinical efficacy.

Prevalence of methicillin-resistant Staphylococcus aureus based on culture and PCR in inpatients at a tertiary care center in Tokyo, Japan.

We investigated active screening for colonization with methicillin-resistant Staphylococcus aureus (MRSA) on admission and weekly follow-up surveillance after admission to a tertiary care center (TCC) between June 2007 and 31 December 2007. Eleven percent (30/267) of patients were found to be positive for MRSA by polymerase chain reaction (PCR) and/or culture on admission; 5% (12/267) became positive during the TCC stay. The major primary diagnoses in MRSA-positive patients were pneumonia and cerebrovascular diseases. Twenty-two (52%) of 42 patients were found to be MRSA positive by both PCR and culture, compared with 19 (45%) of 42 who were PCR positive and culture negative. These findings suggest that active surveillance with PCR is highly sensitive and useful for the detection of MRSA colonization. To our knowledge, this is the first report of active surveillance of MRSA by PCR and bacterial culture in critically ill inpatients in Japan.

Impact of mobile angiography in the emergency department for controlling pelvic fracture hemorrhage with hemodynamic instability.

OBJECTIVE: Rapid trauma evaluation and intervention without time delay are considered integral to time-efficient management of trauma patients, particularly for those with hemodynamic instability. This study examined the impact of immediate availability of mobile angiography with digital subtraction angiography technology in the emergency department (ED) for hemodynamically unstable multiple trauma patients with pelvic injury. MATERIALS: This retrospective review examined a cohort of all blunt trauma patients with pelvic injury who underwent transcatheter arterial embolization (TAE) using mobile angiography by trauma surgeons in the ED. This system was set up on a 24-hour basis with full-time trauma surgeons available in-hospital. Data collected included clinical characteristics, injury severity, resuscitation intervals from admission through to completion of hemostasis, metabolic factors (pH and core body temperature), mortality, and TAE-related complications. RESULTS: Subjects comprised 29 patients (hemodynamically stable group, n = 17; hemodynamically unstable group, n = 12) with a median age of 36 years (interquartile range [IQR], 29-53 years). Mean shock index, injury severity score, and trauma and injury severity score were 1.1 +/- 0.5, 32 +/- 12, and 0.79 +/- 0.27, respectively. Median intervals from ED arrival to diagnosis and from diagnosis to starting TAE were 66 minutes (IQR, 42-80 minutes) and 30 minutes (IQR, 25-37 minutes), respectively. Median interval from diagnosis to completion of TAE was 107 minutes (IQR, 93-130 minutes). Physical and anatomic injury statuses were more severe in the hemodynamically unstable group than in the hemodynamically stable group. However, intervals from diagnosis to starting TAE and from diagnosis to completion of hemostasis did not differ significantly between groups. No exacerbations of metabolic factors during resuscitation were identified. Pelvic injury related mortality was 17% and no TAE-related complications were encountered. CONCLUSION: Immediate availability of mobile angiography in the ED seems safe and effective for hemodynamically unstable trauma patients with pelvic injury and results in a rapid improvement in resuscitation intervals without leaving the ED. An adequately randomized controlled trial of mobile angiography in this subset of patients, who would seem to derive the most benefit from mobile angiography, would be ideal.

Hypothermia during burn surgery and postoperative acute lung injury in extensively burned patients.

BACKGROUND: Respiratory dysfunction remains one of the major complications after burn surgery in extensively burned patients. We evaluated the relationship between the invasiveness of burn surgery and acute lung injury (ALI). METHODS: Patients admitted to our burn unit between 2006 and 2007 with burns greater than or equal to 30% of the total body surface area without severe inhalation injury were entered into this study. Of sixteen patients (mean age, 49.4 +/- 19.3 years, total body surface area 46.0% +/- 14.9%) who underwent burn surgery (3-6 days postburn), vital signs, hemodynamic parameters, blood gas analysis, and peak inspiratory pressure were recorded. Lung injury severity (LIS) score was serially determined. Bronchoalveolar lavage (BAL) was performed before and 24 hour postoperatively. RESULTS: Body temperature and LIS score preoperatively (baseline) were 37.1 degrees C +/- 0.9 degrees C and 3.8 degrees C +/- 2.2 degrees C, respectively. LIS score increased with increased polymorphonuclear neutrophil in BAL 24 hour postoperatively in 7 of 10 patients with intraoperative temperature decreasing more than 1 degrees C. Extent of excision (20.3% +/- 6.7%), transfusion (4.3 +/- 3.0 units), or duration of surgery (147 +/- 49 minutes) alone did not show significant correlation with the development of ALI postoperatively. CONCLUSION: In patients with severe burn injury, hypothermia during surgery despite aggressive intraoperative warming is significantly correlated with the development of ALI with increased polymorphonuclear neutrophil in BAL and may reflect the severity of invasiveness.

Enteral supplementation enriched with glutamine, fiber, and oligosaccharide prevents gut translocation in a bacterial overgrowth model.

BACKGROUND: Normal gut flora plays an important role in the intestinal mucosal barrier function under various critical conditions. The flora may alter after severe insults, such as trauma and shock. Enteral nutrition should preserve the gut environment; however, full support is usually difficult for severely ill patients because of impaired gastrointestinal motility. Currently, we have commercial enteral supplementation product enriched with glutamine, dietary fiber, and oligosaccharide (GFO) in Japan. This study examines the hypothesis that the enteral supplementation ameliorates gut injury induced by a bacterial overgrowth model, even in small volumes and quantities. MATERIALS: Balb/c mice received antibiotics (4 mg/mL of streptomycin) in their drinking water for 4 days to kill the normal gut flora after which they were orally inoculated with a streptomycin-resistant strain of Escherichia coli, known as E. coli C-25. The mice that were administered bacterial monoassociation received 0.5 mL of GFO twice daily (GFO group) or 10% of glucose solution (GLU group). Unsupplemented drinking water was used for control animals (control) whose gut flora was normal. The mice were killed and their mesenteric lymph nodes complex was harvested and processed to test gut bacterial translocation. The cecal population levels of bacteria and ileum histology were also examined. RESULTS: The incidence and magnitude of gut translocation to the lymph nodes complex in the GLU group were significantly higher than those in the control (p < 0.01). Treatment with GFO prevented the gut translocation although animals in the GFO group had same level of the cecal bacterial population. Histologic findings in the ileum were not different between the GLU and GFO. CONCLUSION: GFOs supplement prevented gut translocation for bacterial overgrowth even in small volumes and quantities. The intestinal histologic findings could not explain the protective mechanisms of GFO. Further studies may be needed to elucidate the benefit of the partial enteral nutrition.

Effect of intravenous atrial natriuretic peptide on pulmonary dysfunction and renal function following burn shock.

BACKGROUND: The typical response to burn stress causes burn shock, followed by a diuretic phase; however, fluid management remains crucial in this phase in the treatment of the elderly, patients with preexisting cardiac or renal diseases, and patients developing acute renal failure. We studied the effects of human atrial natriuretic peptide (hANP), which is a renal vasodilator, natriuretic, and inhibitor of renin secretion, on renal function in these patients with burn injuries. METHODS: Thirty-three severely burned patients (44.8% +/- 20.6% total burn surface area) with prolonged cardiovascular overload and pulmonary edema after burn shock receiving a continuous infusion of hANP (0.025 microg/kg/min and 0.05 microg/kg/min, hANP group) were compared with control (no-hANP group, n = 25). Vital signs, urine output (UO) and blood gas analysis before and 72 hour after the start of hANP were recorded. Creatinine clearance, free water clearance, and fractional excretion of sodium were also calculated. RESULTS: Sixteen (48%) patients were elderly, over 80 years old. Twenty (60%) had preexisting cardiovascular disease, renal insufficiency, or diabetes. hANP infusion increased UO in 25 (66%) cases and improved oxygenation in 31 (82%) cases. Treatment with hANP increased creatinine clearance, fractional excretion of sodium, and UO, except in four cases that had already progressed to complete renal failure before the infusion of hANP. CONCLUSIONS: Intravenous hANP seems to be effective for postresuscitative pulmonary dysfunction and renal function after burn shock in the vulnerable elderly, or patients with preexisting disease, suggesting that it could be valuable in facilitating fluid management in the acute phase in severely burned patients.

Introduction of mobile angiography into the trauma resuscitation room.

BACKGROUND: Digital subtraction angiography is frequently required in the initial evaluation of trauma patients. We hypothesized that mobile digital subtraction angiography technology directly into the trauma resuscitation area would save time in restoring metabolic derangements for patients with on-going hemorrhage. MATERIALS: This is a retrospective review of a cohort of trauma patients treated before and after the direct availability of mobile angiography in the trauma resuscitation room performed by the trauma surgeons. Data collected for comparison-included demographics, hemodynamic variables, metabolic factors (pH and temperature), units of blood administered, and outcomes. RESULTS: Mean age, Shock Index, and Injury Severity Score were similar. The interval from the decision to perform transcatheter arterial embolization (TAE) to starting TAE were significantly different (59 minutes +/- 45 minutes vs. 31 minutes +/- 11 minutes, p = 0.001). The other resuscitation intervals were similar. The mean Deltabody temperature from emergency department arrival through completion of TAE between the two groups were significantly different (-1.18 +/- 1.69 vs. -0.08 +/- 1.42, p = 0.026). The mean DeltapH from emergency department arrival through completion of TAE were also significantly different (-0.118 +/- 0.083 vs. 0.028 +/- 0.127, p = 0.001). There were clinically significant correlations between Deltabody temperature and resuscitation interval, and between DeltapH and resuscitation interval. CONCLUSION: The introduction of mobile angiography into the trauma resuscitation room and the immediate availability of trained trauma surgeons to perform diagnostic and therapeutic angiographic procedures shortened the time required to restore normal physiology.

Does splenic preservation treatment (embolization, splenorrhaphy, and partial splenectomy) improve immunologic function and long-term prognosis after splenic injury?

BACKGROUND: : To assess the immunologic alteration and long-term prognosis after splenic injury from preservation treatment (PT) (embolization, splenorrhaphy, partial splencetomy) and to compare with splenectomy (SN). METHODS: : The long-term prognosis of patients with blunt splenic injury treated at seven tertiary emergency centers in Japan was retrospectively studied. Patients were followed up by telephone interview and written questionnaire. Blood samples and abdominal computer tomography scans were taken from patients who consented, and immunologic indices and the remaining volume of the spleen were measured. RESULTS: : There was no episode of severe infection requiring hospitalization among the 66 SN patients (760 patient-year) and the 34 PT (213 patient-year) patients. Blood tests from 58 patients (24 SN vs. 34 PT) revealed significant differences in platelet count, Howell-Jolly body positive rate (SN 87% vs. PT 3%), white blood cells, total lymphocyte count, T-cell count, B-cell count, and serum IgG level. There was no significant difference in serum levels of IgM or specific IgG antibodies against 14 types of Streptococcus pneumoniae capsular polysaccharide, C3, C4, high-sensitivity C-reactive protein, and B -cell subset (surface marker immunoglobulins: IgA, IgG, and IgM). Most patients had anti-S. pneumoniae antibody levels less than that of the reference level for multiple serotypes (average 3 in SN and 4 in PT). A computer tomography scan was taken from 33 PT patients; the volume of spleen remaining averaged 130 mL (range, 48-287 mL). CONCLUSION: : PT did not show discernible advantage over SN in immunologic indices including IgM and 14 serotypes of anti-S. pneumoniae antibodies, suggesting prophylactic measures and close follow-up are necessary after PT and SN.

Endogenous genetic risk factor for serious heatstroke: the thermolabile phenotype of carnitine palmitoyltransferase II variant.

AIM: In serious heatstroke, elevated body temperature (>40°C) is considered the main cause of illness. Mitochondrial carnitine palmitoyltransferase II (CPT II) plays an important role in adenosine triphosphate (ATP) generation from long-chain fatty acids, and its thermolabile phenotype of CPT2 polymorphisms leads to ATP production loss under high fever. Whether by heatstroke or influenza, high fever suppresses mitochondrial ATP production in patients with the thermolabile phenotype of CPT2 polymorphisms. We investigated the relation between CPT2 polymorphism and severity of heatstroke with a body temperature of over 40°C. METHODS: We analyzed blood chemistry test results, Japanese Association for Acute Medicine Disseminated Intravascular Coagulation (JAAM DIC), Acute Physiologic and Chronic Health Evaluation II, and Sequential Organ Failure Assessment (SOFA) scores, and CPT2 polymorphisms in 24 consecutive patients with severe heatstroke at two university hospitals. RESULTS: Eleven patients carried thermolabile CPT II variants (rs2229291; c.1055T˃G [p.Phe352Cys]) (F352C), and the genotype frequency was greater in heatstroke patients than in healthy volunteers. There was no significant difference in body temperature or blood chemistry data at emergency room arrival between patients with and without the CPT II variants. However, hospital days were longer and initial antithrombin activity was significantly lower in the variant group, suggesting a possible link with early phase vascular endothelial cell dysfunction. The JAAM DIC diagnostic criteria and SOFA scores were also higher in the group. There were no differences in the serum albumin, serum creatine kinase, and fibrin degradation product levels, and platelet counts. CONCLUSIONS: In addition to known risks (e.g., environmental temperature and old age), the CPT II polymorphism [F352C] can be a predisposing genetic risk factor for serious heatstroke with organ disfunction, and lower antithrombin activity.

Management of coagulopathy in the patients with multiple injuries: results from an international survey of clinical practice.

BACKGROUND: Bleeding is one of the leading causes of preventable death after traumatic injury. Trauma-associated coagulopathy complicates the control of bleeding. The published approaches on the management of this coagulopathy differ significantly. METHODS: A qualitative international survey of clinical practice among senior physicians responsible for the treatment of patients with multiple injuries (Injury Severity Score > or = 16) was conducted to document common practices, highlight the variabilities, and profile the rationale behind existing clinical practices around the world. RESULTS: Survey results are based on 80 (32%) completed returns, representing 25 countries with 93% of respondents employed by trauma centers and a mean of 20 years clinical experience. There are regional differences in the clinical specialty of physicians responsible for trauma management decisions. Blood loss, temperature, pH, platelets, prothrombin time/INR/activated partial thromboplastin time, and overall clinical assessment, were the most common criteria used to assess coagulopathy. Forty-five percent of respondents claimed to follow a massive transfusion protocol in their institution, 19% reported inconsistent protocol use and 34% do not use a protocol. The management of hypothermia, acidosis, blood products, and adjuvant therapy showed regional as well as institutional variability, and surprisingly few massive transfusion protocols specifically address these issues. CONCLUSIONS: The results of this survey may serve to draw attention to the need for a common definition of coagulopathy and standardized clinical protocols to ensure optimal patient care.

The coagulopathy of trauma: a review of mechanisms.

BACKGROUND: Bleeding is the most frequent cause of preventable death after severe injury. Coagulopathy associated with severe injury complicates the control of bleeding and is associated with increased morbidity and mortality in trauma patients. The causes and mechanisms are multiple and yet to be clearly defined. METHODS: Articles addressing the causes and consequences of trauma-associated coagulopathy were identified and reviewed. Clinical situations in which the various mechanistic causes are important were sought along with quantitative estimates of their importance. RESULTS: Coagulopathy associated with traumatic injury is the result of multiple independent but interacting mechanisms. Early coagulopathy is driven by shock and requires thrombin generation from tissue injury as an initiator. Initiation of coagulation occurs with activation of anticoagulant and fibrinolytic pathways. This Acute Coagulopathy of Trauma-Shock is altered by subsequent events and medical therapies, in particular acidemia, hypothermia, and dilution. There is significant interplay between all mechanisms. CONCLUSIONS: There is limited understanding of the mechanisms by which tissue trauma, shock, and inflammation initiate trauma coagulopathy. Acute Coagulopathy of Trauma-Shock should be considered distinct from disseminated intravascular coagulation as described in other conditions. Rapid diagnosis and directed interventions are important areas for future research.

Traumatic coagulopathy: where are the good experimental models?

BACKGROUND: The development of coagulopathy associated with trauma is a complex process that involves a combination of many factors. It is important to be able to model experimental trauma-related coagulopathy to explore preventative and therapeutic strategies, and numerous models of traumatic coagulopathy have been explored. This systematic review assessed the primary question "What are relevant experimental models with which to study early traumatic coagulopathy?" and secondary questions on mechanisms. METHODS: The author group reviewed 695 abstracts that resulted in 36 articles being fully reviewed by the group. The group identified 12 key studies (grade A) addressing the primary question. A further 10 articles were thought to be relevant but less important (grade B). Eight articles were considered worthwhile publications but not as relevant to the query (grade C), and six articles were considered not relevant after detailed review (grade D). RESULTS: This structured literature review demonstrated a lack of relevant models for human traumatic coagulopathy. We identify challenges in modeling traumatic coagulopathy and limitations to current experimental models and include a proposal for features of an "ideal" model of traumatic coagulopathy, but recognize that this involves major challenges. CONCLUSIONS: Models of traumatic coagulopathy need to more closely resemble human physiology and real-life conditions if they are to influence clinical practice.

Is there a self-preserving hypothermic mechanism in shock?

Hypoxia-induced hypothermia (HIH) is regarded as an adaptive response to hypoxia in a variety of creatures, but no details of the mechanism have yet been elucidated in the clinical setting. This study was designed to analyze alteration of core body temperature with hemorrhagic shock and to clarify HIH in the clinical setting. Patients were categorized in the hemorrhage shock (S, n = 15) or cardiopulmonary arrest (C, n = 88) group. The tympanic membrane temperature (TMT) was measured, and the length of the interval of call-to-arrival (CTA) at a hospital was set as the time-course parameter. There was a significant negative linear relationship between CTA interval and TMT (S group: TMT = -0.055 degrees C, CTA = +36.1 min, r = -0.833, P < 0.001; C group: TMT = -0.046 degrees C, CTA = +36.3 min, r = -0.548, P < 0.001). Analysis of variance revealed no significant difference in the slope of the regression lines of both groups. However, when the CTA interval was used as a covariate, there was a significant difference in the TMT (P = 0.014), which means that the regression line of the S group was significantly lower than that of the C group with time. Furthermore, in the S group, all patients were hypothermic (<35 degrees C) when their CTA interval was more than 20 min; on the other hand, in the C group, only 64 (75%) of 85 were hypothermic. Patients in S group were more likely to become hypothermic (P < 0.05). In humans with cellular hypoxia, HIH takes place, as seen in other animals. This result emphasizes the necessity for studies of analysis of the mechanisms of temperature control and determination of optimal body temperature during acute critical care.

Inhibition of inducible nitric oxide synthase ameliorates lung injury in rats after gut ischemia-reperfusion.

BACKGROUND: Gut hypoperfusion is considered to be a critical event for organ failure during severe surgical insults. The mechanism of remote organ injury after intestinal ischemia-reperfusion (I/R) may involve the excessive nitric oxide (NO) production; however, its role has been controversial. We sought to determine whether a selective inducible NO synthase inhibitor, aminoguanidine (AG), ameliorates pulmonary microvascular injury after superior mesenteric artery occlusion. METHODS: Anesthetized rats underwent superior mesenteric artery occlusion for 30 minutes and reperfusion for 6 hours (I/R) or sham operation (control). Another set of animals undergoing I/R received an AG at the end of the ischemia. Pulmonary vascular permeability was assessed by measuring tissue retention of Evans Blue dye that binds albumin. The plasma was harvested and NO2/NO3 (end products of NO) was measured. The bacterial cultures of the mesenteric lymph node of animals were performed to estimate the gut bacterial translocation after injury. RESULTS: The concentration of NO2/NO3 of plasma in the I/R group was higher than that of the control (p < 0.05). The lung-to-plasma Evans Blue dye ratio in the I/R group was also higher than that of the control (p < 0.01). Treatment with the AG prevented this lung injury induced by the gut I/R. The incidences of gut translocation were not significantly different between the I/R and AG groups. CONCLUSIONS: Increased lung vascular permeability elicited by gut I/R was significantly attenuated with inhibition of an inducible NO release by AG. Control of bacterial translocation was not needed to prevent lung injury in this model.

High-grade traumatic torso visceral injury with hemodynamic instability: effectiveness of transarterial embolization using n-butyl cyanoacrylate.

Trauma patients with uncontrolled hemorrhage encountering coagulopathy are often associated with poor outcome. Recently, the concept of damage control interventional radiology, which focuses on "speedy stoppage of bleeding" by interventional radiology among trauma patients with hemodynamic instability and acute traumatic coagulopathy, was proposed as an alternative to damage control surgery. N-butyl cyanoacrylate (NBCA) has been used as a liquid embolic agent in various non-traumatic situations, where it has been shown to have a high technical success rate and low recurrent bleeding rate, especially in patients with coagulopathy. In this case, we treated a young patient with hemodynamic instability caused by a high-grade hepatic injury, who underwent arterial embolization (AE) using NBCA assisted with resuscitative endovascular balloon occlusion of the aorta and achieved successful hemostasis. A review of published works using PUBMED was carried out, and 10 published reports involving 23 trauma patients who underwent AE using NBCA were identified. Among them, only four reports involving five trauma patients with torso visceral injuries were identified. Three of five patients who were hemodynamically unstable underwent AE using NBCA, resulting in the stabilization of hemodynamics. We concluded that AE with resuscitative endovascular balloon occlusion of the aorta as a damage control interventional radiology procedure might be acceptable for the hemodynamically unstable hepatic injury, and NBCA could be one of the effective hemostatic agents for this purpose, in cases of trauma-induced coagulopathy.

Availability of on-site acute vascular interventional radiology techniques performed by trained acute care specialists: A single-emergency center experience.

INTRODUCTION: Comprehensive treatment of a patient in acute medicine and surgery requires the use of both surgical techniques and other treatment methods. Recently, acute vascular interventional radiology techniques (AVIRTs) have become increasingly popular, enabling adequately trained in-house experts to improve the quality of on-site care. METHODS: After obtaining approval from our institutional ethics committee, we conducted a retrospective study of AVIRT procedures performed by acute care specialists trained in acute medicine and surgery over a 1-year period, including those conducted out of hours. Trained acute care specialists were required to be certified by the Japanese Association of Acute Medicine and to have completed at least 1 year of training as a member of the endovascular team in the radiology department of another university hospital. The study was designed to ensure that at least one of the physicians was available to perform AVIRT within 1 h of a request at any time. Femoral sheath insertion was usually performed by the resident physicians under the guidance of trained acute care specialists. RESULTS: The study sample comprised 77 endovascular procedures for therapeutic AVIRT (trauma, n = 29, and nontrauma, n = 48) among 62 patients (mean age, 64 years; range, 9-88 years), of which 55% were male. Of the procedures, 47% were performed out of hours (trauma, 52%; and nontrauma, 44%). Three patients underwent resuscitative endovascular balloon occlusion of the aorta in the emergency room. No major device-related complications were encountered, and the overall mortality rate within 60 days was 8%. The recorded causes of death included exsanguination (n = 2), pneumonia (n = 2), sepsis (n = 1), and brain death (n = 1). CONCLUSION: When performed by trained acute care specialists, AVIRT seems to be advantageous for acute on-site care and provides good technical success. Therefore, a standard training program should be established for acute care specialists or trauma surgeons to make these techniques a part of the standard regimen. LEVEL OF EVIDENCE: Therapy/care management study, level V.

Empirical research on the utility of a preparation manual for a disaster medical response drill.

PURPOSE: It is difficult for emergency physicians to plan and execute a disaster medical response drill while conducting their daily work activities. Readily available drill preparation manuals are therefore essential, alongside assessment methods to ensure quality. Here, we propose email text analysis as a manual assessment method, and investigate its validity. METHODS: The preparation status of two similar large-scale disaster medical response drills were compared. All email texts exchanged during the preparation stage were analyzed, and frequently appearing words (quality element) and word counts (quantity element) were compared between Drill 1, which was organized without a manual, and Drill 2, organized with a manual. RESULTS: Word frequency analysis revealed that the key components of the manual (visualization of necessary work, preparation of documents in a certain format, and clarification of aims of the drill) contributed to the effectiveness of the preparation process for Drill 2. Furthermore, work volume during the preparation for Drill 2 was decreased by 41.9% from that during the preparation for Drill 1. CONCLUSION: Preparation of a high-quality manual is crucial so that emergency physicians can plan and execute a disaster medical response drill. Email text analysis can serve as an objective method assessing the quality of manuals.