Survival following an out-of-hospital cardiac arrest in Japan in 2020 versus 2019 according to the cause.

Aim: The coronavirus disease (COVID-19) pandemic has led to an increase in out-of-hospital cardiac arrests (OHCAs) and mortality. However, there has been no reports in Japan using nationwide registry data. We compared survival among patients with OHCAs and detailed information on the cause during the COVID-19 pandemic (2020), and during the pre-pandemic period (2019). Methods: Using a Japanese population-based retrospective cohort study design, we analyzed registry data on 39,324 and 39,170 patients with OHCAs in 2019 and 2020, respectively. We compared patient outcomes in 2019 and 2020 using univariable and multivariable logistic regression analyses. Results: The proportion of OHCAs of cardiac origin increased significantly from 61.6% in 2019 to 62.7% in 2020 (P = 0.001). The use of bystander CPR (6.9% versus 5.7%, P < 0.001) and publicaccess automated external defibrillator pads (3.7% versus 3.0%, P < 0.001) decreased significantly from 2019 to 2020. The 1-month survival for OHCA of cardiac origin (12.1% versus 10.7%; adjusted odds ratio [OR] 0.93, 95% confidence interval [CI] 0.87-1.00), asphyxia (10.9% versus 8.8%; adjusted OR 0.80, 95% CI 0.70-0.92), and external causes (adjusted OR 0.66; 95% CI 0.46-0.96), also decreased significantly from 2019 to 2020. Conclusions: In Japan, the 1-month survival after OHCA of cardiac origin, or due to asphyxia or external causes, decreased significantly during the COVID-19 pandemic period.

Association between vasopressor use and mortality in patients with severe traumatic brain injury: a nationwide retrospective cohort study in Japan.

AIM: Vasopressors are frequently incorporated into severe traumatic brain injury management algorithms. However, evidence regarding their clinical effectiveness is lacking. We undertook a nationwide retrospective cohort study to determine the association between vasopressor use and mortality in patients with severe traumatic brain injury. METHODS: Data were collected between January 2004 and December 2018 from the Japanese Trauma Data Bank, which includes data from 272 emergency hospitals in Japan. Adults aged 16 years and over with severe traumatic brain injury but without major extracranial injuries were examined. A severe traumatic brain injury was defined based on a Glasgow Coma Scale score of 3-8 on admission. Multivariable analysis and propensity score matching were carried out. Statistical significance was assessed using 95% confidence intervals. RESULTS: In total, 10,295 patients were eligible for analysis, with 654 included in the vasopressor group and 9,641 included in the nonvasopressor group. The proportion of deaths at hospital discharge was higher in the vasopressor group than in the nonvasopressor group (81.80% [535/654] versus 40.24% [3,880/9,641]). This finding was confirmed in a multivariable logistic regression analysis (adjusted odds ratio, 5.37; 95% confidence interval, 4.23-6.81). Among propensity score-matched patients adjusted for severity, the proportion of deaths at hospital discharge remained higher in the vasopressor group than in the nonvasopressor group (81.87% [533/651] versus 56.22% [366/651]) (odds ratio, 3.52; 95% confidence interval, 2.73-4.53). CONCLUSION: The study results suggest that vasopressor use in patients with severe isolated traumatic brain injury is associated with a higher mortality at hospital discharge.

Survival outcomes after traumatic brain injury during national academic meeting days in Japan.

Surgeons and medical staff attend academic meetings several times a year. However, there is insufficient evidence on the influence of the "meeting effect" on traumatic brain injury (TBI) treatments and outcomes. Using the Japan Trauma Data Bank, we analyzed the data of TBI patients admitted to the hospital from 2004 to 2018 during the national academic meeting days of the Japanese Association for Acute Medicine, the Japanese Society of Intensive Care Medicine, the Japanese Association for the surgery of trauma, the Japan Society of Neurotraumatology and the Japan Neurosurgical Society. The data of these patients were compared with those of TBI patients admitted 1 week before and after the meetings. The primary outcome was in-hospital death. We included 7320 patients in our analyses, with 5139 and 2181 patients admitted during the non-meeting and meeting days, respectively; their in-hospital mortality rates were 15.7% and 14.5%, respectively. No significant differences in in-hospital mortality were found (adjusted odds ratio, 0.93; 95% confidence interval, 0.78-1.11). In addition, there were no significant differences in in-hospital mortality during the meeting and non-meeting days by the type of national meeting. In Japan, it is acceptable for medical professionals involved in TBI treatments to attend national academic meetings without impacting the outcomes of TBI patients.

Traumatic brain injury-related inflammatory projection: beyond local inflammatory responses.

Acute neuroinflammation induced by microglial activation is key for repair and recovery after traumatic brain injury (TBI) and could be necessary for the clearance of harmful substances, such as cell debris. However, recent clinical and preclinical data have shown that TBI causes chronic neuroinflammation, lasting many years in some cases, and leading to chronic neurodegeneration, dementia, and encephalopathy. To evaluate neuroinflammation in vivo, positron-emission tomography has been used to target translocator protein, which is upregulated in activated glial cells. Such studies have suggested that remote neuroinflammation induced by regional microglia persists even after reduced inflammatory responses at the injury site. Furthermore, unregulated inflammatory responses are associated with neurodegeneration. Therefore, elucidation of the role of neuroinflammation in TBI pathology is essential for developing new therapeutic targets for TBI. Treatment of associated progressive disorders requires a deeper understanding of how inflammatory responses to injury are triggered, sustained, and resolved and how they impact neuronal function. In this review, we provide a general overview of the dynamics of immune responses to TBI, from acute to chronic neuroinflammation. We discuss the clinical significance of remote ongoing neuroinflammation, termed "brain injury-related inflammatory projection". We also highlight positron-emission tomography imaging as a promising approach needing further development to facilitate an understanding of post-TBI inflammatory and neurodegenerative processes and to monitor the clinical effects of corresponding new therapeutic strategies.

[Two Cases of Colon Metastasis of Gastric Cancer by Different Metastasis Pathway].

We treated 2 cases ofcolon metastasis ofgastric cancer considered to be caused by different pathway. Case 1 was a 55- year-old male with gastric cancer associated with metastases for lymph node, gallbladder, and liver. Curative surgical treatment of distal gastrectomy, partial hepatectomy, cholecystectomy and lymph node dissection was performed. The final find- ing was, L, Less, Type 3, pT4b(GB), tub2, pN3a(10/20), sP0, CY0, pH1, pM1, Stage IV , R0. Ten months after, ileocecal resection was performed, as a tumor was detected in the cecum. It was a submucosal tumor of well to moderately differentiated adenocarcinoma, and diagnosed as a metastasis ofgastric cancer. Case 2 was a 59-year-old male who received total gastrectomy. The final finding was UE, Less, Type 4, tub2-por2, pT4a, pN2(5/19), cM0, sP0, CY0, Stage III B, R1. One year and 10 months later, unevenness and redness in the mucosal membrane ofthe transverse colon occurred. Signet-ring cells were observed by the endoscopic biopsy, and colon metastasis ofstomach cancer was diagnosed. Consequently, transverse colectomy was performed. Diffused invasion of cancer cells was observed in all layers of the wall, which was considered as metastasis via gastrocolic ligament. Although colon metastasis ofstomach cancer is rare, its pathway varies, such as infiltration, direct invasion, hematogenous, and lymphogenous. Form oflesion also varies. For diagnosis ofcolon lesion occurring during follow-up after gastric cancer, these points should be noted.

[A Very Elderly Patient Successfully Treated by Multimodality Treatment for Pancreas Cancer with Synchronous Multiple Liver Metastases and Liver Dysfunction].

We report an 86-year-old patient successfully treated by multimodality treatment for advanced pancreatic cancer with synchronous multiple liver metastases and liver dysfunction. Systemic chemotherapy(SC)(gemcitabine[GEM]1 g and 5-FU 1 g biweekly)was initiated. Two weeks after, the radiation therapy(55 Gy/25 days)was added. Three weeks after, the short period's high dose hepatic artery infusion(SPHDHAI)(5-FU[1 g]×3 days: 1 day rest: 5-FU[1 g]×3 days)was started. By these treatments, liver dysfunction was completely improved and abdominal pain was disappeared. After 2 times of weekly high dose hepatic artery infusion(WHDHAI)(5-FU 1,500mg), the mixed chemotherapy(MC)(GEM 800 mg[systemic] and 5-FU 1,500 mg hepatic artery infusion:[HAI]biweekly)were started. She could live without admission for about 1 year. About 13 months after lung metastases was appeared and she died about 19 months after first chemotherapy. Our multimodality treatment(systemic and HAI therapy and radiation)was effective for keeping patient quality of life and for improving the survival even if the patient was a very old age and showed liver dysfunction.

[Laparoscopy-Assisted Surgery for Descending Colon Cancer in a Patient with Persistent Descending Mesocolon-A Case Report].

Persistent descending mesocolon(PDM)is caused by absence of fusion of the descending colon to the retroperitoneum. We report a case of laparoscopy-assisted surgery for descending colon cancer in a patient with PDM. An 88-year-oldfemale patient complaining of abdominal pain was diagnosed with bowel obstruction, and referred to our hospital. A computed tomography(CT)scan showed bowel obstruction due to descending colon cancer. After decompression of the colon by insertion of a transanal drainage tube, she underwent laparoscopy-assistedleft hemicolectomy. Intraoperatively it was observed that the descending colon was not fixed to the retroperitoneum, and the patient was diagnosed with persistent descending mesocolon. The accessory middle colic artery and the inferior mesenteric vein branched radially. In patients with PDM, the inferior mesenteric artery often branches radially. However, the various morphologies of branching of the accessory middle colic artery and the inferior mesenteric vein have not been reported. It is not clear whether the radial branching of the accessory middle colic artery and the inferior mesenteric vein is characteristic of patients with PDM. We should however expect radial branching of the accessory middle colic artery and the inferior mesenteric vein in such cases.

[Combination Treatments to the Huge Ovarian Cancer with Liver Metastases].

We report a CR case of huge ovarian cancer with peritoneal and liver metastases who was operated bilateral ovaries, uterus and peritoneal metastases at first, followed by systemic chemotherapy and performed 4 times of radiofrequency ablation (RFA)and 2 times of liver resection(LR). The case was a 50-year-old woman. She suffered with bowel enlargement from over 1 year ago. Preoperative MRI finding was huge ovarian serous cyst with partial solid tumor inside. The major axis was about 30 cm. CA125 and CA19-9 levels were elevated. Tumor reduction surgery was performed with bilateral salpingooophorectomy and hysterectomy with resecting peritoneal metastatic lesions. Postoperative systemic chemotherapy(carbo- platin 550mg/day 1 plus paclitaxel 130mg/day 1, 8, 15)(CBDCA plus PTX)were performed amount 6 courses. Unfortu- nately liver metastases at S3, S4, S6, S7 and S8/5 appeared about 7months after operation.We restarted the CBDCA plus PTX therapy from 15 months after operation when the tumor maker elevated. After 18 courses of CBDCA plus PTX therapy liver metastases remained only at S3. But gradually tumors grew up and size of tumors increased in spite of 3 more courses of CBDCA plus PTX therapy. So we challenged 2 times of RFA at S8/5 metastases that grew most rapidly and the values of increasing tumor makers stopped elevating. Then we performed LR at S3 and S4 metastases and the values of tumor makers returned to the normal level. But next S6 and S7 metastases appeared, we chose the RFA at first. At last recurrence of S7 was resected and all of liver metastases were treated. We checked no peritoneal metastases twice at the time of operation. The values of tumor makers became the normal level. Now she is alive well without metastases over 6 years after first operation. RFA and LR were effective at liver metastases from ovarian cancer that became resistant to systemic chemotherapy.

[Single Incision Laparoscopic Ileocecal Resection for Small Intestinal Malignant Lymphoma - A Case Report].

A 76-year-old man with the chiefcomplaint ofmelena visited our hospital. A mass was palpable in the right lower abdomen. We diagnosed the illness as small intestinal malignant lymphoma in the terminal ileum and performed a single incision laparoscopic ileocecal resection "TANKO-ICR" with D3 lymph node dissection with the idea ofobtaining a wide visualization and surgical field. The Aesculap®internal organ retractor(B BRAUN)is very useful in such cases. We grasped the pedicle of the ileocecal artery using the retractor and pulled out the nylon line connected to the retractor by using ENDO CLOSETM (COVIDIEN)to extraabdomen for drawing the pedicle. Single incision laparoscopic surgery can be performed with only an umbilical wound; therefore, it is minimally invasive and has a superior aesthetic outcome. Small intestinal malignant lymphoma is a relatively rare malignant tumor ofthe digestive organs. We report this case demonstrating that single incision laparoscopic surgery was possible and provide a review ofthe relevant literature.

[The New Liver Retraction Method "V-Shape+1 Method" Using Penrose Drains for Laparoscopic Surgery of the Stomach].

Liver retraction is a necessary operative procedure for enabling greater visualization and a wider surgical field during laparoscopic surgery of the stomach. We have developed a new liver retraction method for laparoscopic surgery that uses penrose drains, is very easy to perform and in minimally invasive. We call this method the "V-Shape+1 method". We performed laparoscopic surgery using this method on 16 patients within 8.3(5.3-13.7)min(median). We analyzed the postoperative changes in the serum levels of AST, ALT, and T-Bil, which are indicators of liver function. The serum AST, ALT values were elevated at postoperative day 1. Thereafter, the values improved immediately. This early liver function failure is acceptable. We have not experienced any complication related to this method. Therefore, we believe this method is useful for obtaining wide visualization easily for not only laparoscopic gastrectomy but also for laparoscopic upper abdominal surgery.

[Efficacy of Combined Therapy(Drainage of the Bile Duct, High-Dose Hepatic Artery Infusion, and Radiation)for Hilar Cholangiocellularcarcinoma with Complete Portal Vein Obstruction].

We reported a case of hilar cholangiocellularcarcinoma with complete obstruction of the portal vein. The patient, who was a 65-year-old woman, suffered from fever and general fatigue as a result of acute cholangitis after insertion of a tube stent into the right bile duct. The main tumor was present on the right side of S1 and spread to both sides of the bile duct. S1 lobe was swollen and diffuse intrahepatic invasion was noted in the right lobe and S1. The portal vein was completely obstructed at the porta hepatis with a coronary vein-left renal vein shunt. We immediately administered a high-dose hepatic arterialinfusion( 5-FU 1 g×3 days: one day off 1 g×3 days)(HDHAI)to the right hepatic artery using a transient catheter insertion method. After 2 courses of HDHAI, the intrahepatic invasion decreased. However, after 4 courses of HDHAI(2 on the right side and 2 on the left side), the invasion on the left side of the IVC had increased. We then chose radiation therapy. Subsequently, transient cystic changes were observed; however, 4 months after radiation, the invasion on the left side of the IVC had regrown into the cardia. The patient suffered from vomiting as a result of the narrowing of the esophagus. We chose HDHAI and dilation of the esophagus using a balloon. Finally, the invasion on the left side of the IVC and S1 swelling decreased, and she could eat again. Thirteen months later, she remains an outpatient. We recommend HDHAI and radiation therapy to hilar cholangiocellularcarcinoma even if the portal vein is completely obstructed.

[Two Year Recurrence Free Survival after Resection of Cutaneous Metastasis from Pancreatic Cancer - A Case Report].

The patient was a 73-year-old woman who underwent distalpancreatectomy for pancreas tailcancer (T3, N0, M0, stage III ). Hepatic arterialinfusion(HAI)using high-dose 5-fluorouracil(5-FU)(6,000mg/week)was performed 35 days after curative resection to prevent liver metastases. Although chemotherapy with gemcitabine(GEM)was administered for 2 weeks, the patient was aware of a nodule(1 cm in diameter)on the right lower quadrant of the abdomen. Resection of the cutaneous mass was performed and histological findings revealed metastatic adenocarcinoma from the pancreas cancer. Six courses of chemotherapy with GEM were administered as adjuvant therapy. Two years after the treatment with GEM, neurological symptoms appeared, and computed tomography(CT)and magnetic resonance imaging(MRI)revealed a solitary metastatic thalamus tumor(2 cm in diameter). After stereotactic radiotherapy, the patient was transferred to a different hospitalfor physicaltherapy. Herein, we report on a case of 2 year recurrence free survivalafter the resection of a cutaneous metastasis from pancreatic cancer.

Cervical impalement injury to a child by a chopstick diagnosed with computed tomography and ultrasonography.

Injuries penetrating into the floor of the mouth in the oral cavity caused by chopsticks are rare. We report a case of neck impalement injury caused by a wooden chopstick fragment penetrating all the way through the base of the tongue. An 18-month-old boy fell off his chair when he was biting on a wooden chopstick. Four centimeters of the chopstick broke off but could not be found, so he was brought to our emergency department with minor bleeding from the tongue. Computed tomography (CT) revealed that the fragment had penetrated through the tongue into the neck. Ultrasonography (US) revealed that the fragment was in close proximity to the common carotid artery. Surgery for the removal of the chopstick tip was uneventful, with minimal soft tissue trauma. Postoperative progress was satisfactory and without complications. Of particular interest is the sensitivity of US in outlining the broken chopstick fragment lodged in the neck. It is noteworthy that the contrast of the chopstick greatly varied between CT and US.