Survival of a hemodynamically unstable pediatric liver trauma patient with aortic balloon occlusion catheter during air transport: A case report.

Background: The utility of resuscitative endovascular balloon occlusion of the aorta (REBOA) in children remains unclear. Case Presentation: An 11-year-old patient with liver trauma with massive extravasation was transported to a local hospital, where an emergency trauma surgery was unavailable. Following the placement of REBOA as a bridge to hemostasis, she was transferred to our hospital by a firefighting helicopter with balloon occlusion. Immediately, she underwent damage control laparotomy and transcatheter arterial embolization. She was subsequently discharged from the hospital 6 months after the accident without complications. Conclusion: REBOA as a bridge to hemostasis may be useful for pediatric patients.

Permissive untreated pseudoaneurysm concept in damage control interventional radiology for traumatic pancreaticoduodenal artery injury.

Background: Angioembolization for traumatic pancreaticoduodenal artery injury with unstable circulation, which characteristically requires a prolonged procedure time, does not yet have a standardized strategy for damage control interventional radiology. Case Presentation: We encountered two cases of rare traumatic pancreaticoduodenal artery injury wherein the patients were saved by a multidisciplinary team with a shared goal of clinical success, rather than the procedural success of angioembolization. Both patients treated with angioembolization had residual pseudoaneurysm or faint extravasation in the pancreaticoduodenal artery arcade. We prioritized critical care with preemptive plasma transfusion and aggressive blood pressure control, and planned repeat angiography. The patients showed no clinical signs of rebleeding or pseudoaneurysm based on computed tomography during follow-up. Conclusion: Our findings suggest that the permissive untreated pseudoaneurysm concept can be useful in developing damage control interventional radiology strategies for trauma cases with challenging time limitations, such as traumatic pancreaticoduodenal artery injury with circulatory collapse.

Incidence and Predictive Factors of Massive Hemothorax Due to Thoracic Vertebral Fractures.

Introduction: Massive hemothorax due to thoracic vertebral fractures (MHTVF) is a potentially lethal condition; however, its epidemiological and clinical data have been rarely described. Thus, in this study, we aimed to evaluate the incidence, predictive factors, and clinical features of MHTVF. Methods: This retrospective cohort study enrolled 202 consecutive patients (136 male and 66 female patients) with thoracic vertebral fractures treated at our institute between January 2009 and December 2019. Their mean age was 60.7 (range, 17-90) years. Unstable fractures accounted for 57.4% (n=116) of the total fractures. The patients were then divided into MHTVF and non-MHTVF groups. We assessed the following MHTVF-associated factors: sex, age, history of medical conditions, anticoagulation/antiplatelet drug use, injury severity score, anatomical distribution of levels of the vertebral fractures, fracture type, and presence or absence of diffuse idiopathic skeletal hyperostosis (DISH) fracture. Results: In total, eight patients (six men and two women) with a mean age of 68.9 years (range, 22-85 years) were determined to exhibit MHTVF. The incidence of MHTVF in patients with unstable thoracic spinal fractures was 6.9%, whereas none of those with stable spinal fractures exhibited MHTVF. Factors like type B (p=0.049) and DISH (p=0.017) fractures were noted to be significantly associated with the MHTVF. Three patients experienced shock upon arrival, whereas two exhibited delayed shock. Chest tube insertion and/or emergency thoracotomy was performed. The survival rate was 100.0%. Conclusions: MHTVF is not rare. Because type B and DISH fractures are identified as predictive factors of MHTVF, it must be carefully treated to avoid preventable death even after hospitalization in patients with these thoracic fractures.

Rapid response system in Japanese outpatient departments based on online registry: Multicentre observational study.

AIM: The rapid response system (RRS) has become well known as a patient safety system to reduce adverse in-patient events, and it is also required to respond to patients in the outpatient department. However, only few studies have reported on the RRS in the outpatient department. We analysed the current status of the RRS in the outpatient department based on a multicentre online registry in Japan. METHODS: This is a prospective multicentre observational study. Among the cases registered in the RRS online registry from January 2014 to March 2018, cases from the outpatient department, consisting of the general outpatient department, radiation department, dialysis department, endoscope department, rehabilitation department, and the surrounding areas were eligible for this study. RESULTS: A total of 6784 cases were registered, and 1022 cases were included. The main reason for activation was altered mental status (39.1%). Incomplete vital sign recording at activation was 67.0%, whereas body temperature (57.0%) and respiratory rate (36.4%) deficits were frequent. The most common intervention during RRS activation was fluid bolus (38.2%) and oxygen supplementation (30.9%). The general outpatient department accounted for nearly half of the activation locations. The 30-day mortality rate for the location was significantly higher in the dialysis department (P < 0.001). CONCLUSIONS: We have reported the first study of RRSs in outpatient departments at multicentre facilities in Japan. The difference in the mortality rate for the location was clarified. Future tasks will involve clarifying the RRS outcome indicators in the outpatient department and examining the effectiveness thereof.

Aortoduodenal fistula successfully treated with endovascular repair.

Aortoduodenal fistula is a rare cause of life-threatening upper gastrointestinal bleeding. Accurate diagnosis is essential to initiate definitive treatment because endoscopic hemostasis, which is the usual initial intervention for upper gastrointestinal bleeding, may be ineffective. This case underscores timely intervention using endovascular treatment for achieving hemostasis in aortoduodenal fistula.

Activities of daily living status and psychiatric symptoms after discharge from an intensive care unit: a single-center 12-month longitudinal prospective study.

AIM: In post-intensive care syndrome (PICS), long-term survivors of critical illness present various physical and mental symptoms that can persist for years after discharge. Post-intensive care syndrome in Japan has not been well described, so this study aims to elucidate its epidemiology. METHODS: We undertook a single-center prospective longitudinal cohort study in a mixed intensive care unit (ICU) in a Japanese tertiary hospital. Adult patients emergently admitted to the ICU were eligible for inclusion in the study. To assess activity of daily living (ADL) status and psychiatric symptoms, we posted a questionnaire at 3 and 12 months after discharge from the ICU. We evaluated ADL status, anxiety, depression, and post-traumatic stress disorder symptoms using the Barthel index, Hospital Anxiety and Depression Scale, and Impact of Event Scale - Revised, respectively. RESULTS: Enrolled in this study were 204 patients. We received responses from 117/147 (80%) and 74/98 (76%) patients at 3 and 12 months, respectively. At 3 months, the prevalence of ADL disability, anxiety, depression, and post-traumatic stress disorder symptoms was 32%, 42%, 48%, and 20%, respectively. At 12 months, the prevalence was 22%, 33%, 39%, and 21%, respectively. The prevalence of any symptoms was 66% at 3 months and 55% at 12 months. Barthel index score at 12 months was improved significantly from that at 3 months. Hospital Anxiety and Depression Scale and Impact of Event Scale - Revised scores at 12 months showed no improvement. CONCLUSIONS: At 3 and 12 months after ICU discharge, over half of our Japanese patients suffered ADL disability and/or psychiatric symptoms. The ADL disability improved at 1 year, but psychiatric symptoms did not.

Prehospital and in-hospital quick Sequential Organ Failure Assessment (qSOFA) scores to predict in-hospital mortality among trauma patients: an analysis of nationwide registry data.

AIM: The quick Sequential Organ Failure Assessment (qSOFA) score can be used to predict in-hospital mortality in trauma patients. We sought to determine whether repeatedly calculating the qSOFA score improves its discriminative ability in predicting in-hospital mortality in trauma patients. METHODS: We undertook a multicenter retrospective study, analyzing 90,974 trauma patients registered in the Japan Trauma Data Bank (a nationwide trauma registry) from 2004 to 2017. Patients included were ≥18 years old and transferred directly to hospitals from their respective scenes of injury. We calculated the qSOFA score at two time points: at the scene (prehospital qSOFA score) and on arrival at the hospital (hospital qSOFA score). We evaluated the discriminative ability of repeated calculations of the qSOFA score. The primary outcome in consideration was in-hospital mortality. RESULTS: In-hospital mortality occurred in 5604 patients (6.2%). The predictive accuracy of the hospital qSOFA score was higher than that of the prehospital qSOFA (area under the receiver operating characteristics curve [AUROC] 0.74 vs. 0.69, P < 0.0001) in predicting in-hospital mortality. However, the mean qSOFA score had the highest predictive accuracy (AUROC 0.76, P < 0.0001). If the hospital qSOFA score was increased compared to the prehospital score, this indicated an approximately 2-fold to 4-fold increase in in-hospital mortality. CONCLUSIONS: Repeated calculations of qSOFA score improved its ability to predict in-hospital mortality in trauma patients. Specifically, we should consider an increasing qSOFA score as a "red flag" to clinicians in the emergency department.

The effect of standard and high dose of rikkunshito on achievement of enteral nutrition target in critically ill patients: a pilot randomized controlled trial.

AIM: Rikkunshito is a traditional Japanese medicine used for delayed gastric emptying in intensive care units in Japan. This study aimed to investigate whether standard- or high-dose rikkunshito can improve the achievement of enteral calorie target among critically ill adults. METHODS: This open-label, single-center, pilot randomized controlled trial was carried out from March 2018 until December 2018 and enrolled critically ill adult patients requiring enteral nutrition by gastric tube for at least 5 days. Patients were randomized into the control group, the standard-dose rikkunshito group (2.5 g three times daily), and the high-dose rikkunshito group (5 g three times daily). Intervention was given for 5 days. The primary outcome measure was the percentage of enteral calorie intake achieved in the target at the fifth day after randomization. RESULTS: The cohort comprised 26 patients; of these, 9, 8, and 9 were included in the control group, the standard-dose group, and the high-dose group, respectively. Twenty-one patients (81%) were included in the primary analysis. The percentage of enteral calorie intake achieved in the target at the fifth day was 59% (interquartile range [IQR], 39-63%), 40% (IQR, 26-61%), and 62% (IQR, 17-83%) in the control, the standard-dose, and the high-dose groups, respectively (P = 0.42). The number of adverse events did not differ significantly between the groups (control group, 4 [44%]; standard-dose group, 3 [38%]; and high-dose group, 4 [44%], P = 1.00). CONCLUSIONS: Standard- or high-dose rikkunshito did not improve the achievement of enteral calorie target in critically ill adults.

Prehospital quick sequential organ failure assessment score to predict in-hospital mortality among patients with trauma.

OBJECTIVE: The quick sequential organ failure assessment (qSOFA) score is calculated from three variables measured at the scene of trauma-systolic blood pressure, respiratory rate and consciousness. This study aimed to evaluate the discriminative ability of the prehospital qSOFA score for in-hospital mortality in patients with trauma. METHODS: This retrospective multicenter study used data from 42,722 patients with trauma included in a Japanese nationwide trauma registry. All included patients were aged ≥18 years old and transferred to hospitals from the scenes of injury. The primary outcome was in-hospital mortality. RESULTS: The included patients had a mean age of 59.4 ±â€¯21.5 years and a male predominance (63%). In-hospital mortality occurred in 2612 patients (6%), while 2-day mortality occurred in 1189 of 42,339 patients (3%). When patients were stratified by qSOFA scores, in-hospital mortality rates of 0.9% (105/11783), 5% (941/17839), 12% (1280/11132) and 15% (286/1968) were associated with qSOFA scores of 0, 1, 2 and 3, respectively (P < 0.0001 for trend). The area under the receiver operating characteristics curve of the qSOFA score for in-hospital mortality was 0.70 (95% confidence interval: 0.69-0.71). A qSOFA score cutoff value ≥1 yielded a sensitivity and specificity of 0.96 and 0.29, respectively, overall, and a sensitivity of 0.99 in patients younger than 65 years. CONCLUSIONS: The prehospital qSOFA score was strongly associated with in-hospital mortality in patients with trauma. A prehospital qSOFA score cutoff of ≥1 can be used to identify patients at a very low risk of death, especially in younger age groups.

Successful endovascular treatment of endoscopically unmanageable hemorrhage from a duodenal ulcer fed by a renal artery: A case report.

A 52-year-old woman was admitted with hypovolemic shock. Emergency endoscopy revealed three hemorrhagic duodenal ulcers (all stage A1) with exposed vessels. Two ulcers were successfully treated by endoscopic clipping; however, the remaining ulcer on the posterior wall of the horizontal portion of the duodenum could not be clipped. Because her vital signs were rapidly worsening, we performed transcatheter arterial embolization (TAE) as it is less invasive than surgery. Computed tomography aortography showed that the duodenal hemorrhage was sourced from the lower branch of the right renal artery. In general, the duodenum is fed by branches from the gastroduodenal artery or superior mesenteric artery. However, this patient had three right renal arteries. The lower branch of the right renal artery at the L3 vertebral level was at the same level as the horizontal portion of the duodenum. Complete hemostasis was achieved by TAE using metallic coils and n-butyl-2-cyanoacrylate. After TAE, she recovered from the hypovolemic shock and was discharged from hospital. She has had no recurrence of the hemorrhagic duodenal ulcer for over 1 yr, and follow-up endoscopy showed no necrosis or stricture of the duodenum. Although she developed a small infarct of her right kidney, her renal function was satisfactory. In summary, the present case is the first reported case of hemorrhagic duodenal ulcer in which the culprit vessel was a renal artery that was successfully treated by TAE. Computed tomography aortography before TAE provides valuable information regarding the source of a duodenal hemorrhage.

Diversity in the incidence and spectrum of organic acidemias, fatty acid oxidation disorders, and amino acid disorders in Asian countries: Selective screening vs. expanded newborn screening.

BACKGROUND: Expanded newborn screening (ENBS) utilizing tandem mass spectrometry (MS/MS) for inborn metabolic diseases (IMDs), such as organic acidemias (OAs), fatty acid oxidation disorders, (FAODs), and amino acid disorders (AAs), is increasingly popular but has not yet been introduced in many Asian countries. This study aimed to determine the incidence rates of OAs, FAODs, and AAs in Asian countries and Germany using selective screening and ENBS records. MATERIALS AND METHODS: Selective screening for IMDs using gas chromatography-mass spectrometry and MS/MS was performed among patients suspected to be afflicted in Asian countries (including Japan, Vietnam, China, and India) between 2000 and 2015, and the results from different countries were compared. Similarly, ENBS results from Japan, South Korea, Taiwan, and Germany were compared. Additionally, the results of selective screening and ENBS in Japan were compared. RESULTS: Among 39,270 patients who underwent selective screening, IMDs were detected in 1170. Methylmalonic acidemia was frequently identified in several countries, including Japan (81/377 diagnosed IMDs), China (94/216 IMDs), and India (72/293 IMDs). In Vietnam, however, ß-ketothiolase deficiency was particularly frequent (33/250 IMDs). ENBS yielded differences in overall IMD rates by country: 1:8557 in Japan, 1:7030 in Taiwan, 1:13,205 in South Korea, and 1:2200 in Germany. Frequently discovered diseases included propionic acidemia (PPA) and phenylketonuria (PKU) in Japan, 3-methylcrotonyl-CoA carboxylase deficiency (MCCD) and PKU in Taiwan, MCCD and citrullinemia type I in South Korea, and PKU and medium-chain acyl-CoA dehydrogenase deficiency in Germany. Furthermore, in Japan, selective screening and ENBS yielded respective PPA frequencies of 14.7% and 49.4% among all organic acidemias. CONCLUSION: The incidence rates of IMDs vary by country. Moreover, the disease spectra of IMDs detected via selective screening differ from those detected via ENBS.

Prehospital quick sequential organ failure assessment as a tool to predict in-hospital mortality.

OBJECTIVE: This study aimed to evaluate the predictive ability of quick sequential organ failure assessment (qSOFA) score for in-hospital mortality among patients transported by physician-staffed helicopters. METHODS: We conducted a single-center, retrospective observational study using the physician-staffed helicopter registry data between 2003 and 2016. We calculated the qSOFA scores based on the patients' vital signs, which were measured on the scene. The tool's discriminatory ability was determined using the area under the curve of the receiver operating characteristic. RESULTS: A total of 1849 patients with a mean age of 63.0 (standard deviation [SD], 18.4) years were included in this study. The diagnostic categories included were trauma and nontrauma cases (1038 [56%] and 811 [44%], respectively). In-hospital mortality was documented in 169 (9%) patients. Meanwhile, the in-hospital mortality rates among patients with qSOFA scores of 0, 1, 2, and 3 were 5/411 (1%), 69/797 (9%), 71/541 (13%), and 24/100 (24%), respectively (P<0.0001 for trend). If the cutoff point is ≥1, the sensitivity and specificity of the qSOFA scores were 0.97 and 0.24, respectively. The area under the curve of the qSOFA scores was 0.67 for all patients, whereas that for trauma patients was 0.75. CONCLUSION: An increase in the qSOFA score is associated with a gradual increase in the in-hospital mortality rate among all patients. In particular, a very low mortality rate was observed among patients with a qSOFA score of 0. The qSOFA score predicted the in-hospital mortality of patients with trauma well.

Outcomes of abdominal trauma patients with hemorrhagic shock requiring emergency laparotomy: efficacy of intra-aortic balloon occlusion.

Aim: The aims of this study were to investigate outcomes of abdominal trauma in patients with hemorrhagic shock requiring emergency laparotomy and clarify the beneficial effects of intra-aortic balloon occlusion (IABO) for intra-abdominal hemorrhage in patients with critically uncontrollable hemorrhagic shock (CUHS). Methods: We reviewed 44 hemorrhagic shock patients who underwent emergency laparotomy for intra-abdominal hemorrhage over a 6-year period. Of these patients, we examined data for 19 subjects who underwent IABO during initial resuscitation to control massive intra-abdominal bleeding leading to CUHS. Results: The average Injury Severity Score and probability of survival (Ps) of the 44 patients were 27.6 ± 15.4 and 0.735 ± 0.304, respectively, and the overall survival rate was 77.3%. The differences in the Glasgow Coma Scale, lactate level, prothrombin time - international normalized ratio, and Ps between the two groups (21 responders and 23 non-responders) were statistically significant (P < 0.05). Intra-aortic balloon occlusion was attempted in 19 of 23 patients (82.6%) with CUHS, and there were no statistically significant differences in presenting Glasgow Coma Scale, body temperature, lactate, prothrombin time - international normalized ratio, or Revised Trauma Score between the survivors (n = 12) and non-survivors (n = 7). The only significant differences between these two groups were observed in Injury Severity Score (P = 0.047) and Ps (P = 0.007). In all patients, the balloons were successfully placed in 8.1 ± 3.3 min in the thoracic aorta, and a significant increase in systolic blood pressure was observed immediately after IABO. Conclusion: The IABO procedure can be life-saving in the management of patients with CUHS arising from intra-abdominal hemorrhage, permitting transport to surgery.

Oxygenation improves during the first 8 h of extended-duration prone positioning in patients with respiratory failure: a retrospective study.

BACKGROUND: A recent multicenter trial demonstrated decreased mortality when patients with acute respiratory distress syndrome were treated with prone positioning (PP). However, the optimal duration of this treatment has not been established. METHODS: From May 2010 to August 2013, 15 patients with respiratory failure underwent extended-duration prone positioning (more than 40 h) in the medical-surgical intensive care unit of a university hospital. The records of each patient were retrospectively investigated to evaluate the impact of prone positioning on the PaO2/FiO2 ratio (PFR) during the first 40 h of therapy. RESULTS: The mean age of the patients was 72.2 ± 7.8 years, and the mean Acute Physiology and Chronic Health Evaluation II score was 19.0 ± 6.0. The hospital mortality rate was 47% (7/15), and the median duration of prone positioning was 47.5 h (46.5-67). The mean PFR before prone positioning was 193.8 ± 70.1, and it significantly improved to 274.7 ± 70.7 (p = 0.02) at 8 h after prone positioning initiation. Although PFR further improved to 294.1 ± 78.0 (p = 0.23) at 16 h, the change was not significant and PFR remained relatively constant at 289.0 ± 88.1, 294.6 ± 68.2, and 291.7 ± 72.7 at 24, 32, and 40 h, respectively. CONCLUSIONS: Extended-duration prone positioning resulted in a progressive improvement in oxygenation until 8 to 16 h after treatment initiation, after which there was no significant improvement. Further studies are warranted to clarify the optimal duration of prone positioning and the actual effectiveness of extended-duration PP for respiratory failure.

UV-B light induces an adaptive response to UV-C exposure via photoreactivation activity in Euglena gracilis.

Phytoplankton such as Euglena are constantly exposed to solar light which is used for photosynthesis. Although the solar ultraviolet (UV) induces DNA damage such as cyclobutane-pyrimidine dimers (CPDs), many kinds of living organisms can repair CPDs by photoreactivation (PR) utilizing the near-UV/blue light component in sunlight. Euglena cells are known to possess such PR activity. In the present paper, the formation of CPDs induced by UV-C exposure and the photoreactivation PR repair of these CPDs by UV-A are demonstrated. To clarify the adaptive responses prior UV-B irradiation on PR activity, cells were cultured in the dark or under UV-B light. When the cells were cultured in the dark for 3 d prior to UV-C exposure, PR activity decreased. When the cells were cultured under UV-B light, however, PR activity increased. These results suggest that exposing the cells to UV-B prior to exposure to UV-C induced an adaptive response towards DNA damage caused by UV-C exposure, and this UV-C induced damage was repaired through PR activity.

Korormicin insensitivity in Vibrio alginolyticus is correlated with a single point mutation of Gly-140 in the NqrB subunit of the Na(+)-translocating NADH-quinone reductase.

Na(+)-translocating NADH-quinone reductase (NQR) from the marine Vibrio alginolyticus is strongly inhibited by a new antibiotic korormicin. Korormicin specifically inhibits the Na(+)-dependent reaction of the NQR complex and acts as a purely non-competitive inhibitor for Q-1 with the inhibitor constant of 82 pM. Korormicin-resistant mutants were isolated from V. alginolyticus and the NQR complex was purified from a mutant KR2. Similar to 2-n-heptyl-4-hydroxyquinoline N-oxide (HQNO), korormicin acted as a purely noncompetitive inhibitor to the NQR complex from the mutant KR2, but the inhibitor constant increased to 8 microM, which is 10(5)-fold higher than that of the wild-type NQR complex. The inhibitor constant of HQNO, however, was only slightly affected by the acquisition of korormicin resistance. The spontaneous mutation was caused by a single mutation of G-422 to T-422 in the nucleotide sequence of the nqrB gene, which resulted in the conversion of Gly-140 to Val-140. Thus, Gly-140 seems to play an important role for the binding of korormicin to the NqrB subunit. The fact that korormicin is a purely noncompetitive inhibitor for Q-1 strongly supports the presence of one of Q-1 binding sites in the NqrB subunit, which also has a covalently bound FMN at Thr-235.