Association between Postoperative Adjuvant Vasodilator Therapy and In-Hospital Mortality for Non-Occlusive Mesenteric Ischemia: A Nationwide Observational Study.

BACKGROUND: Although several clinical guidelines recommend vasodilator therapy for non-occlusive mesenteric ischemia (NOMI) and immediate surgery when bowel necrosis is suspected, these recommendations are based on limited evidence. METHODS: In this retrospective nationwide observational study, we used information from the Japanese Diagnosis Procedure Combination inpatient database from July 2010 to March 2018 to identify patients with NOMI who underwent abdominal surgeries on the day of admission. We compared patients who received postoperative vasodilator therapy (vasodilator group) with those who did not (control group). Vasodilator therapy was defined as venous and/or arterial administration of papaverine and/or prostaglandin E1 within 2 days of admission. The primary outcome was in-hospital mortality. Secondary outcomes included the prevalence of additional abdominal surgery performed ≥3 days after admission and short bowel syndrome. RESULTS: We identified 928 eligible patients (149 in the vasodilator group and 779 in the control group). One-to-four propensity score matching yielded 149 and 596 patients for the vasodilator and control groups, respectively. There was no significant difference in in-hospital mortality between the groups (control vs. vasodilator, 27.5% vs. 30.9%; risk difference, 3.4%; 95% confidence interval, -4.9 to 11.6; p=0.42) and no significant difference in the prevalences of abdominal surgery, bowel resection ≥3 days after admission, and short bowel syndrome. CONCLUSIONS: Postoperative vasodilator use was not significantly associated with a reduction in in-hospital mortality or additional abdominal surgery performed ≥3 days after admission in surgically treated NOMI patients.

Venous Congestive Ischemic Colitis After Sigmoid Colectomy: A Case Report.

Venous congestion is a possible cause of ischemic colitis following colorectal surgery. As such, congestive ischemic colitis should be considered in such cases where the mesenteric artery is preserved. Herein, we describe the case of a 73-year-old man who presented to the hospital with a two-week history of difficult defecation and frequent mucous stools and was subsequently diagnosed with refractory ischemic enterocolitis due to venous congestion. The patient had undergone resection of the sigmoid colon cancer with preservation of the inferior mesenteric artery 11 months before presentation. Contrast-enhanced abdominal computed tomography revealed edematous wall thickening on the anal side of the anastomosis. A colonoscopy revealed a normal mucosa extending from the anastomosis to the descending colon; however, mucosal swelling, erythema, and erosion were observed on the rectal side of the anastomosis. Based on these findings, he was diagnosed with ischemic colitis. After two months of ineffective conservative treatment, the patient underwent surgery. Ischemic colitis was diagnosed as venous congestion based on the histopathological examination. Preservation of the mesenteric artery may result in ischemic colitis due to an imbalance between the arterial and venous blood flow. Chronic ischemic colitis due to venous congestion should be considered in cases of mesenteric artery preservation to reduce anastomotic leakage.

Risk factors for the need for advanced care among prescription and over-the-counter drug overdose patients.

Aim: Prescription drug and over-the-counter (OTC) drug overdose is a major problem in emergency departments in Japan, and some need advanced care which is more than observation. We aimed to identify the prehospital risk factors for the need of advanced care among overdose patients. Methods: This was a single-center retrospective cohort study. We included overdoses patients of prescription drugs or OTC drugs, who admitted to our hospital between 2016 and 2021. We grouped them into advanced care and non-advanced care. The main outcome was the need for advanced care. We performed a multiple logistic regression analysis, calculated the PAV score (Paracetamol use, Alcohol use, abnormal Vital signs on scene) and performed a receiver operating characteristic (ROC) analysis. Results: There were 229 subjects. The logistic regression analysis revealed that alcohol, paracetamol, and the abnormal vital signs on scene were associated with advanced care (alcohol-odds ratio [OR]: 2.95; 95% confidence interval [CI]: 1.29-6.75; paracetamol-OR: 5.47; 95% CI: 2.18-13.71; abnormal vital signs-OR: 4.61, 95% CI: 2.07-10.27). The rate of advanced care in the high PAV score (2 and 3) group was statistically higher than that in the low PAV score (0-1) group (p = 0.04). Area under the ROC curve of the PAV score was 0.72 (95% CI, 0.65-0.80). Conclusion: Alcohol, paracetamol use and abnormal vital signs on scene might be risk factors for advanced care among prescription drugs or OTC drugs overdose patients, and the PAV score may predict the need for advanced care.

Development and validation of a novel overhead method for anteroposterior radiographs of fractured rat femurs.

We aimed to establish a new method of obtaining femur anteroposterior radiographs from live rats. We used five adult male Sprague-Dawley rats and created a femoral fracture model with an 8 mm segmental fragment. After the surgery, we obtained two femoral anteroposterior radiographs, a novel overhead method, and a traditional craniocaudal view. We obtained the overhead method three times, craniocaudal view once, and anteroposterior radiograph of the isolated femoral bone after euthanasia. We compared the overhead method and craniocaudal view with an isolated femoral anteroposterior view. We used a two-sample t-test and intraclass correlation coefficient (ICC) to estimate the intra-observer reliability. The overhead method had significantly smaller differences than the craniocaudal view for nail length (1.53 ± 1.26 vs. 11.4 ± 3.45, p < 0.001, ICC 0.96) and neck shaft angle (5.82 ± 3.8 vs. 37.8 ± 5.7, p < 0.001, ICC 0.96). No significant differences existed for intertrochanteric length/femoral head diameter (0.23 ± 0.13 vs. 0.23 ± 0.13, p = 0.96, ICC 0.98) or lateral condyle/medial condyle width (0.15 ± 0.16 vs. 0.13 ± 0.08, p = 0.82, ICC 0.99). A fragment displacement was within 0.11 mm (2.4%). The overhead method was closer to the isolated femoral anteroposterior view and had higher reliability.

Association of initial lactate levels and red blood cell transfusion strategy with outcomes after severe trauma: a post hoc analysis of the RESTRIC trial.

BACKGROUND: The appropriateness of a restrictive transfusion strategy for those with active bleeding after traumatic injury remains uncertain. Given the association between tissue hypoxia and lactate levels, we hypothesized that the optimal transfusion strategy may differ based on lactate levels. This post hoc analysis of the RESTRIC trial sought to investigate the association between transfusion strategies and patient outcomes based on initial lactate levels. METHODS: We performed a post hoc analysis of the RESTRIC trial, a cluster-randomized, crossover, non-inferiority multicenter trials, comparing a restrictive and liberal red blood cell transfusion strategy for adult trauma patients at risk of major bleeding. This was conducted during the initial phase of trauma resuscitation; from emergency department arrival up to 7 days after hospital admission or intensive care unit (ICU) discharge. Patients were grouped by lactate levels at emergency department arrival: low (< 2.5 mmol/L), middle (≥ 2.5 and < 4.0 mmol/L), and high (≥ 4.0 mmol/L). We compared 28 days mortality and ICU-free and ventilator-free days using multiple linear regression among groups. RESULTS: Of the 422 RESTRIC trial participants, 396 were analyzed, with low (n = 131), middle (n = 113), and high (n = 152) lactate. Across all lactate groups, 28 days mortality was similar between strategies. However, in the low lactate group, the restrictive approach correlated with more ICU-free (ß coefficient 3.16; 95% CI 0.45 to 5.86) and ventilator-free days (ß coefficient 2.72; 95% CI 0.18 to 5.26) compared to the liberal strategy. These findings persisted even after excluding patients with severe traumatic brain injury. CONCLUSIONS: Our results suggest that restrictive transfusion strategy might not have a significant impact on 28-day survival rates, regardless of lactate levels. However, the liberal transfusion strategy may lead to shorter ICU- and ventilator-free days for patients with low initial blood lactate levels.

Evaluation of clinical response to empirical antimicrobial therapy on day 7 and mortality in the intensive care unit: sub-analysis of the DIANA study Japanese data.

It is not clear whether evaluating the clinical response to antibiotic use at day 7 among critically ill patients accurately predicts outcomes. We aimed to evaluate the relationship between clinical response to the initial empiric therapy on day 7 and mortality. Methods: The determinants of antimicrobial use and de-escalation in critical care (DIANA) study was an international, multicenter, observational study on antibiotic use in the intensive care unit (ICU). ICU patients ages over 18 years in whom an empiric antimicrobial regimen in Japan was initiated were included. We compared patients who were evaluated as cured or improved ("effective") 7 days after starting antibiotic treatment with patients who were evaluated as deteriorated ("failure"). Results: Overall, 217 (83%) patients were in the effective group, and 45 (17%) were in the failure group. Both the infection-related mortality rate in the ICU and the in-hospital infection-related mortality rate in the effective group were lower than those in the failure group (0% versus 24.4%; P < 0.01 and 0.5% versus 28.9%; P < 0.01, respectively). Conclusion: Assessment of efficacy of empiric antimicrobial treatment on day 7 may predict a favorable outcome among patients suffering from infection in the ICU.

Diagnostic value of transpulmonary thermodilution measurements for acute respiratory distress syndrome in a pig model of septic shock.

BACKGROUND: No direct approach assessing pulmonary vascular permeability exists in the current therapeutic strategy for patients with acute respiratory distress syndrome (ARDS). Transpulmonary thermodilution measures hemodynamic parameters such as pulmonary vascular permeability index and extravascular lung water, enabling clinicians to assess ARDS severity. The aim of this study is to explore a precise transpulmonary thermodilution-based criteria for quantifying the severity of lung injury using a clinically relevant septic-ARDS pig model. METHODS: Thirteen female pigs (weight: 31 ± 2 kg) were intubated, mechanically ventilated under anesthesia, and either assigned to septic shock-induced ARDS or control group. To confirm the development of ARDS, we performed computed tomography (CT) imaging in randomly selected animals. The pulmonary vascular permeability index, extravascular lung water, and other hemodynamic parameters were consecutively measured during the development of septic lung injury. Lung status was categorized as normal (partial pressure of oxygen/fraction of inspired oxygen ≥ 400), or injured at different degrees: pre-ARDS (300-400), mild-to-moderate ARDS (100-300), or severe ARDS (< 100). We also measured serum inflammatory cytokines and high mobility group box 1 levels during the experiment to explore the relationship of the pulmonary vascular permeability index with these inflammatory markers. RESULTS: Using CT image, we verified that animals subjected to ARDS presented an extent of consolidation in bilateral gravitationally dependent gradient that expands over time, with diffuse ground-glass opacification. Further, the post-mortem histopathological analysis for lung tissue identified the key features of diffuse alveolar damage in all animals subjected to ARDS. Both pulmonary vascular permeability index and extravascular lung water increased significantly, according to disease severity. Receiver operating characteristic analysis demonstrated that a cut-off value of 3.9 for the permeability index provided optimal sensitivity and specificity for predicting severe ARDS (area under the curve: 0.99, 95% confidence interval, 0.98-1.00; sensitivity = 100%, and specificity = 92.5%). The pulmonary vascular permeability index was superior in its diagnostic value than extravascular lung water. Furthermore, the pulmonary vascular permeability index was significantly associated with multiple parameters reflecting clinicopathological changes in animals with ARDS. CONCLUSION: The pulmonary vascular permeability index is an effective indicator to measure septic ARDS severity.

Extravascular lung water levels are associated with mortality: a systematic review and meta-analysis.

BACKGROUND: The prognostic value of extravascular lung water (EVLW) measured by transpulmonary thermodilution (TPTD) in critically ill patients is debated. We performed a systematic review and meta-analysis of studies assessing the effects of TPTD-estimated EVLW on mortality in critically ill patients. METHODS: Cohort studies published in English from Embase, MEDLINE, and the Cochrane Database of Systematic Reviews from 1960 to 1 June 2021 were systematically searched. From eligible studies, the values of the odds ratio (OR) of EVLW as a risk factor for mortality, and the value of EVLW in survivors and non-survivors were extracted. Pooled OR were calculated from available studies. Mean differences and standard deviation of the EVLW between survivors and non-survivors were calculated. A random effects model was computed on the weighted mean differences across the two groups to estimate the pooled size effect. Subgroup analyses were performed to explore the possible sources of heterogeneity. RESULTS: Of the 18 studies included (1296 patients), OR could be extracted from 11 studies including 905 patients (464 survivors vs. 441 non-survivors), and 17 studies reported EVLW values of survivors and non-survivors, including 1246 patients (680 survivors vs. 566 non-survivors). The pooled OR of EVLW for mortality from eleven studies was 1.69 (95% confidence interval (CI) [1.22; 2.34], p < 0.0015). EVLW was significantly lower in survivors than non-survivors, with a mean difference of -4.97 mL/kg (95% CI [-6.54; -3.41], p < 0.001). The results regarding OR and mean differences were consistent in subgroup analyses. CONCLUSIONS: The value of EVLW measured by TPTD is associated with mortality in critically ill patients and is significantly higher in non-survivors than in survivors. This finding may also be interpreted as an indirect confirmation of the reliability of TPTD for estimating EVLW at the bedside. Nevertheless, our results should be considered cautiously due to the high risk of bias of many studies included in the meta-analysis and the low rating of certainty of evidence. Trial registration the study protocol was prospectively registered on PROSPERO: CRD42019126985.

Comparison of the effectiveness of pericardiocentesis and surgical pericardiotomy in the prognosis of patients with blunt traumatic cardiac tamponade: a multicenter study using the Japan Trauma Data Bank.

Aim: To compare the prognostic impact of pericardiocentesis (PCC) and surgical pericardiotomy (SP) in blunt traumatic pericardial tamponade. Methods: Among 361,706 trauma patients registered in the Japan Trauma Data Bank from January 2004 to December 2018, we included those with blunt traumatic cardiac tamponade who underwent PCC and/or SP. We excluded patients with penetrating trauma, age younger than 15 years, Injury Severity Score (ISS) equal to 75, blood pressure 0 mmHg at the time of admission, head Abbreviated Injury Scale (AIS) score 5 or more, and those with missing data for outcomes. To examine the effect of SP, patients were divided into a PCC group and an SP-only group. Missing values of age, sex, systolic blood pressure, respiratory rate, pulse rate, time from emergency call to hospital arrival, head AIS, chest AIS, abdomen/pelvis AIS, Glasgow Coma Scale score, and ISS were estimated using multiple imputation. In-hospital mortality was analyzed using multivariable analysis, and we undertook a survival analysis. Results: We analyzed 305 patients, 150 (49.2%) in the PCC group and 155 (50.8%) in the SP-only group. The in-hospital mortality rate was 40.7% in the PCC group and 76.8% in the SP-only group. Multivariable analysis after multiple imputation showed an odds ratio of SP for in-hospital mortality 5.34 (95% confidence interval, 2.80-10.18; P < 0.01) compared with PCC. Using the Kaplan-Meier method, SP showed a significant risk of mortality (hazard ratio 2.16; 95% confidence interval, 1.58-2.95; P < 0.01). Conclusions: In patients with blunt traumatic cardiac tamponade, SP was associated with poor prognosis.

Airway obstruction time and outcomes in patients with foreign body airway obstruction: multicenter observational choking investigation.

Aim: Foreign body airway obstruction (FBAO) is a major public health concern worldwide for infants and older adults. This study determines the association between airway obstruction time and neurological outcomes to plan an effective response for patients with FBAO. Methods: This multicenter retrospective observational study was carried out among patients with life-threatening FBAO in Japan over a period of 4 years. The duration of airway obstruction was calculated from the time of the accident to the time of foreign body removal. The study examined the relationship between airway obstruction time and outcome. The primary outcome was vegetative state or death at hospital discharge. Results: Among 119 patients, 68 were in the category of vegetative state or death. Logistic regression analysis showed that longer airway obstruction time (adjusted odds ratio 1.04; 95% confidence interval 1.01-1.07) was associated with vegetative state or death. When the cut-off value was set at 10, the sensitivity was 0.88, the specificity 0.47, with the area under the curve 0.69. Using the other cut-off value of 4 min, the negative predictive value was 1.00. Conclusion: Longer airway obstruction time was associated with vegetative state or death for patients with FBAO. The incidence of vegetative state or death increased when the airway obstruction time exceeded 10 min. Meanwhile, 4 min or less may be set as a target time for foreign body removal in order to prevent vegetative state or death and plan an effective response.

Neuromyelitis optica with rapid respiratory failure: a case report.

BACKGROUND: Neuromyelitis optica is an inflammatory demyelinating disease of the central nervous system and is characterized by severe optic neuritis and transverse myelitis. CASE PRESENTATION: The patient was a 74-year-old man with pneumonia. On admission, he exhibited lower limb weakness and rapid respiratory deterioration in the form of tachypnea. Subsequently, he was transported to the Emergency Center of our hospital. High-signal lesions were observed from the cervical spinal cord to the thoracic spinal cord on T2-weighted spinal magnetic resonance images. Neuromyelitis optica was suspected, and the patient received steroid pulse therapy and immunoadsorption plasmapheresis. Serum samples obtained upon transfer were positive for anti-aquaporin-4 antibodies, which confirmed the diagnosis of neuromyelitis optica. Thereafter, the patient was transferred to a rehabilitation hospital. CONCLUSION: Rapid respiratory failure in neuromyelitis optica is rare, and care is needed while treating these cases.

Restrictive transfusion strategy for critically injured patients (RESTRIC) trial: a study protocol for a cluster-randomised, crossover non-inferiority trial.

INTRODUCTION: Resuscitation using blood products is critical during the acute postinjury period. However, the optimal target haemoglobin (Hb) levels have not been adequately investigated. With the restrictive transfusion strategy for critically injured patients (RESTRIC) trial, we aim to compare the restrictive and liberal red blood cell (RBC) transfusion strategies. METHODS AND ANALYSIS: This is a cluster-randomised, crossover, non-inferiority trial of patients with severe trauma at 22 hospitals that have been randomised in a 1:1 ratio based on the use of a restrictive or liberal transfusion strategy with target Hb levels of 70-90 or 100-120 g/L, respectively, during the first year. Subsequently, after 1-month washout period, another transfusion strategy will be applied for an additional year. RBC transfusion requirements are usually unclear on arrival at the emergency department. Therefore, patients with severe bleeding, which could lead to haemorrhagic shock, will be included in the trial based on the attending physician's judgement. Each RBC transfusion strategy will be applied until 7 days postadmission to the hospital or discharge from the intensive care unit. The outcomes measured will include the 28-day survival rate after arrival at the emergency department (primary), the cumulative amount of blood transfused, event-free days and frequency of transfusion-associated lung injury and organ failure (secondary). Demonstration of the non-inferiority of restrictive transfusion will emphasise its clinical advantages. ETHICS AND DISSEMINATION: The trial will be performed according to the Japanese and International Ethical guidelines. It has been approved by the Ethics Committee of each participating hospital and The Japanese Association for the Surgery of Trauma (JAST). Written informed consent will be obtained from all patients or their representatives. The results of the trial will be disseminated to the participating hospitals and board-certified educational institutions of JAST, submitted to peer-reviewed journals for publication, and presented at congresses. TRIAL REGISTRATION NUMBER: UMIN Clinical Trials Registry; UMIN000034405. Registered 8 October 2018.

Impact of population aging on the presentation of out-of-hospital cardiac arrest in the Pan Asian Resuscitation Outcomes Study.

AIM: As a population ages, it can impact on the characteristics and outcomes of cardiogenic out-of-hospital cardiac arrest (OHCA) patients. This study aimed to evaluate the relationship between the age incidence of cardiogenic OHCA and population aging. METHODS: This was a post-hoc analysis of the Pan Asian Resuscitation Outcomes Study (PAROS) database. Data on the population old-age dependency ratio (i.e. elderly/non-elderly) were extracted from publicly accessible sources (United Nations and World Health Organization). RESULTS: We analyzed 40,872 OHCA cases from seven PAROS countries over the period 2009 to 2013. We found significant correlation between the population old-age dependency ratio and elderly/non-elderly ratio in OHCA patients (r = 0.92, P = 0.003). There was a significant correlation between the population old-age dependency ratio and risk differences of 30-day survival rates for non-elderly and elderly OHCA patients (r = 0.89, P = 0.007). CONCLUSIONS: Our findings suggest that the proportion of elderly among OHCA patients will increase, and outcomes could increasingly differ between elderly and non-elderly as a society ages progressively. This has implications for planning and delivery of emergency services as a society ages.

The Japanese Intensive care PAtient Database (JIPAD): A national intensive care unit registry in Japan.

PURPOSE: The Japanese Intensive care PAtient Database (JIPAD) was established to construct a high-quality Japanese intensive care unit (ICU) database. MATERIALS AND METHODS: A data collection structure for consecutive ICU admissions in adults (≥16 years) and children (≤15 years) has been established in Japan since 2014. We herein report a current summary of the data in JIPAD for admissions between April 2015 and March 2017. RESULTS: There were 21,617 ICU admissions from 21 ICUs (217 beds) including 8416 (38.9%) for postoperative or procedural monitoring, defined as adult admissions following elective surgery or for procedures and discharged alive within 24 h, 11,755 (54.4%) critically ill adults other than monitoring, and 1446 (6.7%) children. The standardized mortality ratios (SMRs) based on the Acute Physiology and Chronic Health Evaluation (APACHE) III-j, APACHE II, and Simplified Acute Physiology Score II scores in adults ranged from 0.387 to 0.534, whereas the SMR based on the Paediatric Index of Mortality 2 in children was 0.867. CONCLUSION: The data revealed that the SMRs based on general severity scores in adults were low because of high proportions of elective and monitoring admission. The development of a new mortality prediction model for Japanese ICU patients is needed.

Early versus late surgery after cervical spinal cord injury: a Japanese nationwide trauma database study.

BACKGROUND: The management of cervical spinal cord injury (SCI) has changed drastically in the last decades, and surgery is the primary treatment. However, the optimum timing of early surgical treatment (within 24 h or 72 h after injury) is still controversial. We sought to determine the optimum timing of surgery for cervical SCI, comparing the length of the intensive care unit (ICU) stay and in-hospital mortality in patients who underwent surgical treatments (decompression and stabilization) for cervical SCI within 24 h after injury and within 7 days after injury. METHODS: This was a retrospective cohort study using Japan Trauma Data Bank (JTDB) which is a nationwide, multicenter database. We selected adult isolated cervical SCI patients who underwent operative management within 7 days after injury, between 2004 and 2015. The main outcome measures were the length of ICU stay and in-hospital mortality. We grouped the patients into two, based on the time from onset of injury to surgery, an early group (within 24 h) and a late group (from 25 h to 7 days). Next, we performed multivariable analyses for analyzing the relevance between the timing of surgery and the length of ICU stay after adjusting for baseline characteristics using propensity score. We also performed the Cox survival analyses to evaluate in-hospital mortality. RESULTS: From 236,698 trauma patients registered in JTDB, we analyzed 514 patients. The early group comprised 291 patients (56.6%), and the late group comprised 223 (43.4%). The length of ICU stay did not differ between the two groups (early, 10 days; late, 11 days; p = 0.29). There was no significant difference for length of ICU stay between the early and late group even after adjustment by multivariate analysis (p = 0.64). There was no significant difference in in-hospital mortality between the two groups (the early group 3.8%, the late group 2.2%, p = 0.32), and no significant difference was found in the Cox survival analysis. CONCLUSIONS: Our study showed that neither the length of ICU stay nor in-hospital mortality after spinal column stabilization or spinal cord decompression for cervical SCI significantly differed according to the timing of surgery between 24 h and 7 days.

Functional Outcome Following Ultra-Early Treatment for Ruptured Aneurysms in Patients with Poor-Grade Subarachnoid Hemorrhage.

BACKGROUND: Little is known regarding functional outcome following poor-grade (World Federation of Neurosurgical Societies grades IV and V) aneurysmal subarachnoid hemorrhage (aSAH), especially in individuals treated aggressively in the early phase after ictus. METHODS: We provided patients with aSAH with ultra-early definitive treatment, coiling or clipping, within 6 hours from arrival as per protocol. We classified the patients into 3 groups according to their computed tomography findings: Group 1, intraventricular hemorrhage with obstructive hydrocephalus; Group 2, massive intracerebral hemorrhage with brain herniation; and Group 3, neither Group 1 nor Group 2. We retrospectively evaluated patients with poor-grade aSAH who were admitted to our department between January 2013 and December 2016. We evaluated functional outcome at 6 months, defining modified Rankin Scale (mRS) scores of 0-2 as good and those of 3-6 as poor outcomes. RESULTS: A good functional outcome was observed in 39.4% (28/71) of all cases. All-cause mortality at 6 months was 15.5% (11/71). A good outcome in Group 3 was significantly higher than that in the other two groups (Group 1 and 2 vs. Group 3, 20.8% vs. 48.9%, p = 0.02), even after adjustment with a multiple logistic regression analysis (odds ratio 6.1, 95% confidence interval 1.1 to 34.8). CONCLUSIONS: Approximately 40% of patients with poor-grade aSAH became functionally independent, and approximately half of the patients with poor-grade aSAH who had neither intraventricular hemorrhage with obstructive hydrocephalus nor with brain herniation had good functional outcomes. Although further trials are required to confirm our results, ultra-early surgery may be considered for patients with poor-grade aSAH.

New classifications for Life-threatening foreign body airway obstruction.

INTRODUCTION: Foreign body airway obstruction (FBAO) is a common medical emergency; however, few studies of life-threatening FBAO have been reported and no standard classification system is available. METHODS: We retrospectively evaluated patients who presented to the emergency departments of two hospitals and were diagnosed with FBAO. The primary outcome was cerebral performance category (CPC) score at discharge. To establish a new classification system for FBAO, FBAO was classified into three types based on the anatomical and physiological characteristics of the obstructed airway. RESULTS: A total of 137 patients were enrolled. Median age was 79.0 years. The most common cause of FBAO was meat, followed by bread, rice cake, and rice. Of all patients, 65.7% suffered cardiac arrest and 51.1% died. In contrast, 28.5% had favorable neurological outcomes, defined as CPC 1 and 2. Upper airway obstruction (type 1) was the most common (type 1, 78.1%), while trachea and/or bilateral main bronchus obstruction (type 2, 12.4%) showed significantly higher mortality than type 1 obstruction (82.4% vs 47.7%, P = 0.0078). Patients with unilateral bronchus and/or distal bronchus obstruction (type 3, 9.5%) were significantly more likely to consume a dysphagia diet than type 1 patients (23.1% vs 0%, P < 0.0001). CONCLUSION: The majority of patients with life-threatening FBAO were elderly and had poor neurological outcomes. Our new classification system divides FBAO into three types, and revealed that mortality was significantly higher with type 2 than type 1 obstruction. This classification system may improve the management of patients with FBAO and assessment of patient outcomes.

Endoscopic Treatment of Boerhaave Syndrome Using Polyglycolic Acid Sheets and Fibrin Glue: A Report of Two Cases.

Boerhaave syndrome, the spontaneous perforation of the esophagus, is an emergency, life-threatening condition. Current endoscopic treatment options include clipping and stenting, but the use of polyglycolic acid (PGA) sheets for treating the condition has not been reported. In recent years, PGA sheets have been used after endoscopic submucosal dissection to prevent perforations and stricture formation in patients treated for early-stage carcinoma. We report the cases of two patients with Boerhaave syndrome who were successfully treated using PGA sheets. The present clinical outcomes suggest that the use of PGA sheets is feasible and safe for treating patients with Boerhaave syndrome, and that they may be another treatment option.

Recent trends in 30-day mortality in patients with blunt splenic injury: A nationwide trauma database study in Japan.

BACKGROUND: Splenic injury frequently occurs after blunt abdominal trauma; however, limited epidemiological data regarding mortality are available. We aimed to investigate mortality rate trends after blunt splenic injury in Japan. METHODS: We retrospectively identified 1,721 adults with blunt splenic injury (American Association for the Surgery of Trauma splenic injury scale grades III-V) from the 2004-2014 Japan Trauma Data Bank. We grouped the records of these patients into 3 time phases: phase I (2004-2008), phase II (2009-2012), and phase III (2013-2014). Over the 3 phases, we analysed 30-day mortality rates and investigated their association with the prevalence of certain initial interventions (Mantel-Haenszel trend test). We further performed multiple imputation and multivariable analyses for comparing the characteristics and outcomes of patients who underwent TAE or splenectomy/splenorrhaphy, adjusting for known potential confounders and for within-hospital clustering using generalised estimating equation. RESULTS: Over time, there was a significant decrease in 30-day mortality after splenic injury (p < 0.01). Logistic regression analysis revealed that mortality significantly decreased over time (from phase I to phase II, odds ratio: 0.39, 95% confidence interval: 0.22-0.67; from phase I to phase III, odds ratio: 0.34, 95% confidence interval: 0.19-0.62) for the overall cohort. While the 30-day mortality for splenectomy/splenorrhaphy diminished significantly over time (p = 0.01), there were no significant differences regarding mortality for non-operative management, with or without transcatheter arterial embolisation (p = 0.43, p = 0.29, respectively). CONCLUSIONS: In Japan, in-hospital 30-day mortality rates decreased significantly after splenic injury between 2004 and 2014, even after adjustment for within-hospital clustering and other factors independently associated with mortality. Over time, mortality rates decreased significantly after splenectomy/splenorrhaphy, but not after non-operative management. This information is useful for clinicians when making decisions about treatments for patients with blunt splenic injury.

Antithrombin use and 28-day in-hospital mortality among severe-burn patients: an observational nationwide study.

BACKGROUND: Previous studies have suggested that antithrombin may be beneficial for treating coagulopathy in patients with severe burns. However, robust evidence for this idea is lacking. We examined the hypothesis that antithrombin may be effective in treating patients with severe burns. METHODS: We performed propensity score-matched analyses of the nationwide administrative Japanese Diagnosis Procedure Combination inpatient database. We identified patients with severe burns (burn index ≥ 10) who were recorded in the database from 1 July 2010 to 31 March 2013. We compared patients who were administered antithrombin within 2 days of admission (antithrombin group) and those who were not administered antithrombin (control group). The main outcomes were 28-day mortality and ventilator-free days (VFDs). RESULTS: Eligible patients (n = 3223) from 618 hospitals were categorized into either an antithrombin group (n = 152) or control group (n = 3071). Propensity score matching created a matched cohort of 103 pairs with and without antithrombin. Twenty-eight-day mortality was lower in the antithrombin group compared with the control group in propensity-matched analysis (control vs. antithrombin, 47.6 vs. 33.0%; difference, 14.6%; 95% confidence interval [CI] 1.2-28.0). Cox regression analysis showed a significant difference in 28-day in-hospital mortality between the control and antithrombin propensity-matched groups (hazard ratio 0.58; 95% CI 0.37-0.90). There were significantly more VFDs in the antithrombin compared with the control group in propensity score-matched analysis (control vs. antithrombin, 12.6 vs. 16.4 days; difference -3.7; 95% CI -7.2 to -0.12). CONCLUSIONS: This nationwide database study demonstrated that antithrombin use may improve 28-day survival and increase VFDs in patients with severe burns. Further prospective studies are required to confirm these results.