Characteristics and outcomes of out-of-hospital cardiac arrest in a hilly area: Utstein Registry data from the Nagasaki Medical Region, Japan.

Aim: To analyze characteristics and investigate prognostic indicators of out-of-hospital cardiac arrest (OHCA) in a hilly area in Japan. Methods: A retrospective population-based study was conducted using the Utstein Registry for 4280 OHCA patients in the Nagasaki Medical Region (NMR) registered over the 10-year period from 2011 to 2020. The main outcome measure was a favorable cerebral performance category (CPC 1-2). Sites at which OHCA occurred were classified into "sloped places (SPs)" (not easily accessible by emergency medical services [EMS] personnel due to slopes) and "accessible places (APs)" (EMS personnel could park an ambulance close to the site). The characteristics and prognosis based on CPC were compared between SPs and APs, and multivariable analysis was performed. Results: No significant improvement in prognosis occurred in the NMR from 2011 to 2020. Prognosis in SPs was significantly worse than that in APs. However, multivariable analysis did not identify SP as a prognostic indicator. The following factors were associated with survival and CPC 1-2: age group, witness status, first documented rhythm, bystander-initiated cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) use, use of mechanical CPR (m-CPR) device or esophageal obturator airway (EOA), and year. Both m-CPR and EOA use were associated with a poor prognosis. Conclusion: In a hilly area, OHCA patients in SPs had a worse prognosis than those in APs, but SPs was not significantly associated with prognosis by multivariable analysis. Interventions to increase bystander-initiated CPR and AED use could potentially improve outcomes of OHCA in the NMR.

Balance of the prooxidant and antioxidant system is associated with mortality in critically ill patients.

It is well known that oxidative stress causes certain diseases and organ damage. However, roles of oxidative stress in the acute phase of critical patients remain to be elucidated. This study aimed to investigate the balance of oxidative and antioxidative system and to clarify the association between oxidative stress and mortality in critically ill patients. This cohort study enrolled 247 patients transported to our emergency department by ambulance. Blood was drawn on hospital arrival, and serum derivatives of reactive oxidant metabolites (dROMs, oxidative index) and biological antioxidant potential (BAP, antioxidative index) were measured. Modified ratio (MR) is also calculated as BAP/dROMs/7.51. There were 197 survivors and 50 non-survivors. In the non-survivors, dROMs were significantly lower (274 vs 311, p<0.01), BAP was significantly higher (2,853 vs 2,138, p<0.01), and MR was significantly higher (1.51 vs 0.92, p<0.01) compared to those in the survivors. The AUC of MR was similar to that for the APACHE II score. Contrary to our expectations, higher BAP and lower dROMs were observed on admission in non-survivors. This may suggest that the antioxidative system is more dominant in the acute phase of severe insults and that the balance toward a higher antioxidative system is associated with mortality.

Current situation survey for establishing personally acceptable radiation dose limits for nuclear disaster responders.

When responding to disasters, emergency preparedness is essential to ensure that disaster activities are performed smoothly, safely and efficiently. Investigations on the Fukushima accident revealed that lack of preparedness, poor communication and unsuitable emergency measures contributed to an inadequate emergency response to the nuclear disaster. In this study, we conducted a questionnaire survey on the establishment of a personal radiation exposure dose among Disaster Medical Assistance Team (DMAT) members in Japan who might be involved in the initial response to a nuclear disaster. Establishing personal exposure doses for personnel can encourage emergency preparedness and inform decisions on appropriate role assignments during nuclear response activities. Valid responses were obtained from 178 participants, and the response distribution was as follows: 'Already have own acceptable dose standard,' 16 (9%); 'Follow own institution's standard (and know its value),' 30 (17%); 'Follow own institution's standard (but do not know its value),' 59 (33%); 'Haven't decided,' 63 (35%) and 'Don't understand question meaning,' 10 (6%). We also assessed intention to engage in nuclear disaster activities among respondents via engagement intent scores (EIS) and found that participants who had established personal exposure standards had significantly higher EIS scores than those who had not decided or who did not understand the question. Thus, educating potential nuclear disaster responders on personal exposure doses may contribute to a higher intention to engage in emergency responses and improve preparedness and response efficiency.

The expression of repulsive guidance molecule a after traumatic brain injury: Time-course changes in gene expression in a murine model of controlled cortical impact.

INTRODUCTION: Repulsive guidance molecule a (RGMa) is a key protein that negatively regulates neuronal regeneration as its inhibition enhances axonal growth and promotes functional recovery in animal models of spinal cord injury. However, the role of RGMa in traumatic brain injury (TBI) remains elusive. This study aimed to clarify TBI-responsive RGMa expression in a murine model. METHODS: Adult male C57BL/6J mice were subjected to controlled cortical impact. Brains were extracted 6 hours and 1, 3, 7, 14 and 21 days after injury (n = 6 in each group). Changes in the messenger RNA (mRNA) expression of RGMa and its receptor, neogenin, were evaluated by quantitative polymerase chain reaction in the damaged area of the cortex and contralateral cortex, along with expression measurement of inflammation-related molecules. Neurological deficit was also assessed by the cylinder test. RESULTS: Neurological score was consistently lower in the TBI group compared to the sham group throughout the experimental period. The mRNA expressions of representative inflammatory cytokine TNF-α and chemokine receptor CCR2 were remarkably increased in the injured cortex on day 1 and gradually decreased over time, although remaining at higher values at least until day 14. The mRNA expressions of RGMa and neogenin were significantly suppressed in the damaged cortex until day 3. Interestingly, RGMa expression was suppressed most on day 1 and recovered over time. CONCLUSION: In the acute phase of TBI, gene expression of inflammatory cytokines significantly increased, and gene expressions of RGMa and neogenin significantly decreased in the inflammatory milieu of the damaged area. Despite the subsequent remission of inflammation, RGMa gene expression recovered to the normal level 1 week after TBI. Intrinsic regenerative response to acute brain injury might be hampered by the following recovery of RGMa expression, hinting at the possibility of functional RGMa inhibition as a new, effective maneuver against TBI.

Impact of fecal short-chain fatty acids on prognosis in critically ill patients.

AIM: This study aimed to evaluate the relationship between fecal organic acids and mortality in critically ill patients. METHODS: This retrospective study included 128 patients who fulfilled the criteria of systemic inflammatory response syndrome and had a serum C-reactive protein level of greater than 10 mg/dL. Patients were treated in the intensive care unit for more than 2 days. Patients were divided into two groups: survivors and non-survivors. We measured and compared eight kinds of fecal organic acids between the two groups. We focused on the minimum and maximum value of each fecal organic acid and evaluated prognostic factors by using classification and regression tree (CART) and multivariate logistic regression analyses. RESULTS: We included 90 patients as survivors and 38 as non-survivors. The CART analysis revealed that the dominant factors for mortality were the minimum values of propionate and acetate and the maximum values of lactate and formic acid. In the evaluation of the minimum values of fecal organic acids, propionate was significantly associated with increased mortality (odds ratio, 0.11 [95% confidence interval, 0.024-0.51]; P = 0.005), acetate (0.047 [0.005-0.49]; P = 0.01), and age (1.048 [1.015-1.083]; P = 0.004). In the evaluation of the maximum values, lactate was significantly associated with increased mortality (5.21 [2.024-13.42], P = 0.001) and age (1.050 [1.017-1.084]; P = 0.003). CONCLUSION: An altered balance of fecal organic acids was significantly associated with mortality in critically ill patients.

Effects of a trauma center on early mortality after trauma in a regional city in Japan: a population-based study.

BACKGROUND: Although the effects of the trauma center(TC) were researched in several studies, there have been few studies on changes in the regional mortality due to the implementation of a TC. An emergency medical center (EMC) and TC were implemented at Nagasaki University Hospital (NUH) for the first time in the Nagasaki medical region of Japan in April 2010 and October 2011, respectively, and they have cooperated with each other in treating trauma patients. The purpose of this study was to investigate the effects on the early mortality at population level of a TC working in cooperation with an EMC. METHODS: This is a retrospective study using standardized regional data (ambulance service record) in Nagasaki medical region from April 2007 through March 2017. We included 19,045 trauma patients directly transported from the scene. The outcome measures were prognosis for one week. To examine the association between the implementation of the EMC and TC and mortality at a region, we fit adjusted logistic regression models. RESULTS: The number of patients of each fiscal year increased from 1492 in 2007 to 2101 in 2016. The number of all patients transported to NUH decreased until 2009 to 70, but increased after implementation of the EMC and TC. Overall mortality of all patients in the region improved from 2.3% in 2007 to 1.0% in 2016. In multivariate logistic regression model, odds ratio of death was significantly smaller at 2013 and thereafter if the data from 2007 to 2011 was taken as reference. CONCLUSIONS: Implementation of the EMC and TC was associated with early mortality in trauma patients directly transported from the scene by ambulance. Our analysis suggested that the implementation of EMC and TC contributed to the improvement of the early mortality at a regional city with 500000 populations. LEVEL OF EVIDENCE: Level III.

Novel screening criteria for post-traumatic venous thromboembolism by using D-dimer.

AIM: Because severe trauma patients frequently manifest coagulopathy, it is extremely important to detect venous thromboembolism (VTE) in the acute phase. However, no reference value for D-dimer in post-traumatic VTE has been reported given the substantial increase in its levels after injury. Therefore, this study evaluates the ability of our screening criteria using D-dimer to detect VTE in severe trauma patients. METHODS: Trauma patients (n = 455) who were admitted to our emergency medical center during October 2011-June 2015 were included in this study. To prevent VTE, intermittent pneumatic compression was carried out in most patients. Our screening criteria included the following: (i) ≥5 days of hospital stay, (ii) increasing D-dimer levels across 3 measuring days, (iii) D-dimer levels ≥15 µg/mL. Patients who met these screening criteria underwent contrast-enhanced computed tomography (CE-CT) to detect VTE. RESULTS: During the study period, 108 cases satisfied the screening criteria; 73 of these underwent CE-CT, 34 of whom were diagnosed with VTE (positive predictive value, 46.6%). The median hospital stay on satisfying the screening criteria and before undergoing CE-CT was 7 and 10 days, respectively. No patient had VTE symptoms at the time of diagnosis. Also, none of the remaining 347 patients who did not satisfy the screening criteria had VTE symptoms. CONCLUSION: The screening criteria using D-dimer presented herein can be used as reference for efficiently detecting VTE in severe trauma patients.

The profile of Japanese Association for Acute Medicine - out-of-hospital cardiac arrest registry in 2014-2015.

AIM: To describe the registry design of the Japanese Association for Acute Medicine - out-of-hospital cardiac arrest (JAAM-OHCA) Registry as well as its profile on hospital information, patient and emergency medical service characteristics, and in-hospital procedures and outcomes among patients with OHCA who were transported to the participating institutions. METHODS: The special committee aiming to improve the survival after OHCA by providing evidence-based therapeutic strategies and emergency medical systems from the JAAM has launched a multicenter, prospective registry that enrolled OHCA patients who were transported to critical care medical centers or hospitals with an emergency care department. The primary outcome was a favorable neurological status 1 month after OHCA. RESULTS: Between June 2014 and December 2015, a total of 12,024 eligible patients with OHCA were registered in 73 participating institutions. The mean age of the patients was 69.2 years, and 61.0% of them were male. The first documented shockable rhythm on arrival of emergency medical services was 9.0%. After hospital arrival, 9.4% underwent defibrillation, 68.9% tracheal intubation, 3.7% extracorporeal cardiopulmonary resuscitation, 3.0% intra-aortic balloon pumping, 6.4% coronary angiography, 3.0% percutaneous coronary intervention, 6.4% targeted temperature management, and 81.1% adrenaline administration. The proportion of cerebral performance category 1 or 2 at 1 month after OHCA was 3.9% among adult patients and 5.5% among pediatric patients. CONCLUSIONS: The special committee of the JAAM launched the JAAM-OHCA Registry in June 2014 and continuously gathers data on OHCA patients. This registry can provide valuable information to establish appropriate therapeutic strategies for OHCA patients in the near future.

Early diagnosis using canonical discriminant analysis of innate immune receptor gene expression profiles in a murine infectious or sterile systemic inflammation model.

BACKGROUND: Infection in patients with systemic inflammation is difficult to diagnose with a single biomarker. We aimed to clarify the time course of change in the gene expression profile of innate immune receptors in infectious or sterile inflammation and to establish an early diagnostic method using canonical discriminant analysis (CDA) of the gene expression profile. METHODS: To compare infectious and sterile inflammation, we used cecal ligation and puncture (CLP) and 20% full-thickness burn injury (Burn) models. C57BL/6 mice underwent sham treatment (n = 9 × three groups), CLP (n = 12 × three groups), or Burn (n = 12 × three groups) injury. Mice were killed at 6, 12, and 24 hours after injury, and total RNA was extracted from whole blood. We used quantitative real-time polymerase chain reaction to investigate gene expression of innate immune receptors Toll-like receptor 2 (TLR2), TLR4, TLR9, NLRP3 (nucleotide-binding oligomerization domain-like receptor family pyrin domain containing 3), and retinoic acid-inducible gene I. To evaluate all gene expression together as patterns, each value was standardized, and CDA was performed at each time point. RESULTS: Gene expression of TLR2 and TLR4 was already significantly increased in both CLP and Burn compared with sham mice at 6 hours after injury (p < 0.05). Gene expression of TLR9 was significantly decreased in CLP compared with sham and Burn mice at 12 hours and 24 hours after injury (p < 0.05) but not at 6 hours. Gene expression of NLRP3 was significantly increased in CLP and Burn compared with sham mice at 6 hours and 24 hours after injury (p < 0.05). In the CDA, each group showed distinctive gene expression patterns at only 6 hours after injury. Each group was clearly classified, and the classification error rates were 0% at all of the time points. CONCLUSIONS: Canonical discriminant analysis of the gene expression profile of innate immune receptors could be a novel approach for diagnosing the pathophysiology of complicated systemic inflammation from the early stage of injury.

Delayed massive epistaxis from traumatic intracranial aneurysm after blunt facial injury.

Cases: Traumatic intracranial aneurysm following blunt head injury is uncommon but can be induced by extension of skull base fracture and causes unexpected hemorrhagic complications. We present two cases of traumatic intracranial aneurysm in the paraclinoid area that was revealed by delayed massive epistaxis. Lack of initial neurological deficits omitted screening for cerebrovascular injury. Outcome: Internal trapping was carried out using endovascular techniques in both cases, with extracranial-intracranial bypass in one case. No recurrent bleeding occurred in either case. Conclusion: To prevent unexpected delayed life-threatening hemorrhagic accidents, careful assessment of skull-base fracture is prerequisite, even in cases of mild facial injury.

An adult case of laryngopharyngeal burn by drinking hot water.

Case: A 61-year-old man who was hospitalized with schizophrenia in a psychiatric hospital drank hot water estimated to be 90°C. Eight hours after injury, laryngopharynx edema gradually progressed, and his breathing deteriorated. Upon arrival at our emergency room, we secured his respiratory tract by nasal intubation under a bronchoscope. Outcome: The edema gradually improved after peaking at hospital day 2, and he was extubated on hospital day 18. There were no apparent respiratory or esophageal problems, and he was discharged back to the psychiatric hospital on day 28. Conclusion: These types of laryngopharynx burns caused by ingesting hot foods or drinks have been rarely reported for adults. In cases of adults, when the patient is in a special situation such as having a psychiatric disorder, it is necessary to assume that the laryngopharynx burns might be aggravated.

Portable system for monitoring of regional cerebral oxygen saturation during prehospital cardiopulmonary resuscitation: a pilot study.

Aim: We aimed to create a system for monitoring of regional cerebral oxygen saturation (rSO 2) in patients with prehospital cardiopulmonary arrest and clarify the changes in rSO 2 during cardiopulmonary resuscitation. Methods: We measured rSO 2 in cardiopulmonary arrest patients who were transferred by the emergency response vehicle of Nagasaki University Hospital. We developed a portable rSO 2 monitor (HAND ai TOS), which is small enough to carry during prehospital treatment. The sensor is attached to the forehead of the patient and monitors rSO 2 continuously during treatment and transfer. Results: No difficulties were experienced in monitoring rSO 2 during patient treatment and transfer. Median time (interquartile range) from the emergency medical service call to emergency response vehicle arrival was 15.0 min (11.0-19.5 min). Median rSO 2 on emergency response vehicle arrival at the scene was 46.3% (44.0-48.2%) (n = 9; median age, 74.0 years; four men, five women). Median rSO 2 showed significant increase within 5 min after return of spontaneous circulation (n = 6, 46.6% versus 58.7%, P < 0.05). There was no significant increase in rSO 2 during prehospital cardiopulmonary resuscitation until return of spontaneous circulation was established. Conclusions: We developed an rSO 2 monitoring system for use during prehospital cardiopulmonary resuscitation. The monitoring system showed a significant increase in rSO 2 after return of spontaneous circulation, whereas there was no significant increase in rSO 2 during cardiopulmonary resuscitation after intubation but before return of spontaneous circulation.

Altered balance of the aminogram in patients with sepsis - the relation to mortality.

BACKGROUND & AIMS: Protein metabolism is important in healing wounds, supporting immune function, and maintaining lean body mass. Determination of adequate requirements of amino acids has not been thoroughly clarified in critically ill patients. The purpose of this study was to evaluate 23 plasma amino acids in patients with sepsis and determine prognostic factors. METHODS: This study was a retrospective study. Plasma aminograms were measured in patients with sepsis. We evaluated minimum and maximum values of each amino acid and evaluated prognostic factors by multivariate logistic regression analysis and classification and regression tree (CART) analysis. RESULTS: The study comprised 77 patients. The median intensive care unit (ICU) stay was 30 days (interquartile range 19.5-55.5 days). Whole mortality rate was 39.0%. Maximum values of glutamine, glutamate, glycine, alanine, methionine, phenylalanine, and histidine and minimum values of glutamate, taurine, serine, isoleucine, leucine, tyrosine, ornithine, tryptophan, and arginine were significantly different between survivors and non-survivors (P < 0.05). Statistical analysis using CART analysis revealed the minimum value of glutamate and maximum value of methionine to be significant prognostic factors for mortality (P < 0.05). CONCLUSION: Plasma aminograms were significantly altered in patients with sepsis. Altered balance of aminograms was significantly associated with mortality in patients with sepsis requiring a long ICU stay.

Outcome prediction model for severe traumatic brain injury.

AIM: Treatment of severe traumatic brain injury is aided by better prediction of outcomes. The purpose of the present study was to develop and validate a prediction model using retrospective analysis of prospectively collected clinical data from two tertiary critical care medical centers in Japan. METHODS: Data were collected from 253 patients with a Glasgow Coma Scale score of <9. Within 24 h of their admission, 15 factors possibly related to outcome were evaluated. The dataset was randomly split into training and validation datasets using the repeated random subsampling method. A logistic regression model was fitted to the training dataset and predictive accuracy was assessed using the validation data. RESULTS: The best model included the variables age, pupillary light reflex, extensive subarachnoid hemorrhage, intracranial pressure, and midline shift. The estimated area under the curve for the model development data was 0.957, with a 95% confidence interval of 0.926-0.987, and that for validation data was 0.947, with a 95% confidence interval of 0.909-0.980. CONCLUSION: Our predictive model was shown to have high predictive value. It will be useful for review of treatment, family counseling, and efficient allocation of resources for patients with severe traumatic brain injury.

Actual treatments for out-of-hospital ventricular fibrillation at critical care medical centers in Osaka: a pilot descriptive study.

AIM: Although advanced treatments are provided to improve outcomes after out-of-hospital ventricular fibrillation, including shock-resistant ventricular fibrillation, the actual treatments in clinical settings have been insufficiently investigated. The aim of the current study is to describe the actual treatments carried out for out-of-hospital ventricular fibrillation patients, including shock-resistant ventricular fibrillation patients, at critical care medical centers. METHODS: We registered consecutive adult patients suffering bystander-witnessed out-of-hospital cardiac arrest of cardiac origin, for whom resuscitation was attempted by emergency medical service personnel, who had ventricular fibrillation as an initial rhythm, and who were transported to critical care medical centers in Osaka from March 2008 to December 2008. This study merged data on treatments after transportation, collected from 11 critical care medical centers in Osaka with the prehospital Utstein-style database. RESULTS: During the study period, there were 260 bystander-witnessed ventricular fibrillation arrests of cardiac origin. Of them, 252 received defibrillations before hospital arrival, 112 (44.4%) were transported to critical care medical centers, and 35 had shock-resistant ventricular fibrillation. At the critical care medical centers, 54% (19/35), 40% (14/35), and 46% (16/35) of shock-resistant ventricular fibrillation patients were treated with extracorporeal life support, percutaneous coronary interventions, and therapeutic hypothermia, respectively, but their treatments differed among institutions. Some patients with prolonged arrest without prehospital return of spontaneous circulation who received advanced treatments had neurologically favorable survival, whereas approximately two-thirds of shock-resistant ventricular fibrillation patients with advanced treatments did not. CONCLUSION: This pilot descriptive study suggested that actual treatments for prehospital ventricular fibrillation patients differed between critical care medical centers. Further studies are warranted to evaluate the effectiveness of in-hospital advanced treatments for ventricular fibrillation including shock-resistant ventricular fibrillation.

Delayed formation of splenic pseudoaneurysm following nonoperative management in blunt splenic injury: multi-institutional study in Osaka, Japan.

BACKGROUND: Delayed rupture is well-known as a severe complication after splenic injury treated with nonoperative management (NOM). The incidence and timing of splenic pseudoaneurysm (SPA) formation, which is a cause of delayed rupture following splenic injury, have not been thoroughly investigated, and the timing of follow-up computed tomography (CT) is controversial. The objective of this study was to clarify the incidence and timing of both the delayed formation and spontaneous resolution of SPA following splenic injuries treated with NOM in several trauma centers in Japan. METHODS: This was a retrospective review of all patients with documented blunt splenic injury who were treated with NOM from 2003 through 2010 in five trauma and critical care centers. RESULTS: The present study consisted of 104 patients, including 16 patients (15.4%) with delayed formation of SPA (7 patients with Grade II and 9 with Grade III) during their clinical course. SPA was diagnosed with enhanced CT at a mean (SD) of 4.6 (2.1) hospital days (range, 1-8 days) after admission. Delayed formation of SPA was found in 30.4% of Grade II injuries and in 18.4% of Grade III injuries. Eight patients with delayed formation of SPA were observed without transcatheter arterial embolization during their entire stay. These SPAs were spontaneously occluded on follow-up enhanced CT or angiography. Spontaneous occlusion of SPA was confirmed at 5.2 (2.6) hospital days (range, 2-10 days) after diagnosis of delayed SPA. CONCLUSION: Delayed formation of SPAs was recognized with enhanced helical CT in 15% of all patients during hospital Days 1 to 8. About one half of the SPAs had occluded spontaneously without therapeutic intervention. Our results suggested that follow-up enhanced CT performed approximately 1 week after splenic injury may be useful to detect delayed SPA formation. LEVEL OF EVIDENCE: Epidemiologic study, level III.

Delayed progression of edema formation around a hematoma expressing high levels of VEGF and mmp-9 in a patient with traumatic brain injury: case report.

The mechanisms accounting for the development of tissue damage following traumatic brain injury (TBI) have been studied for several decades. A variety of mediators, such as vascular endothelial growth factor (VEGF) and matrix metalloproteinase-9 (MMP-9), which play a crucial role in edema formation after TBI, have been identified. We experienced a case of brain edema that progressed continuously at least until 13 days after head injury. The brain edema occurred around the hemorrhage from an intracerebral contusion. The evacuated hematoma was investigated based on the inference that the unexpected expansion of edema was induced by the mediators within the hematoma itself. A 64-year-old woman was admitted to our hospital following a traffic injury. Left brain contusion was revealed by head computed tomography (CT) on admission. Three hours later, formation of an intracerebral hematoma became evident. Serial CT examination revealed that brain edema had developed progressively till 13 days after the injury. A hematoma removal operation was performed on Day 13. The hematoma was centrifuged and the supernatant was analyzed for the expression of VEGF and MMP-9. The values of both (4400 pg/ml and 920 ng/ml, respectively) were extremely high compared with values reported previously in serum and cerebrospinal fluid collected from patients with intracranial infection or injury. This case suggested that the delayed exacerbation of edema following traumatic intracranial hemorrhage was possibly induced by secretory factors such as VEGF and MMP-9 released from within and around the hematoma.

Impact on survival of whole-body computed tomography before emergency bleeding control in patients with severe blunt trauma.

INTRODUCTION: Whole-body computed tomography (CT) has gained importance in the early diagnostic phase of trauma care. However, the diagnostic value of CT for seriously injured patients is not thoroughly clarified. This study assessed whether preoperative CT beneficially affected survival of patients with blunt trauma who required emergency bleeding control. METHODS: This retrospective study was conducted from January 2004 to December 2010 in two tertiary trauma centers in Japan. The primary inclusion criterion was patients with blunt trauma who required emergency bleeding control (surgery or transcatheter arterial embolization). CT before emergency bleeding control was performed at the attending physician's discretion based on individual patient condition (for example, hemodynamic stability or certain abnormalities in the primary survey). We assessed covariates associated with 28-day mortality with multivariate logistic regression analysis and evaluated standardized mortality ratio (SMR, ratio of observed to predicted mortality by Trauma and Injury Severity Score (TRISS) method) in two subgroups of patients who did or did not undergo CT. RESULTS: The inclusion criterion was fulfilled by 152 patients with a median Injury Severity Score of 35.3. During the early resuscitation phase, 132 (87%) patients underwent CT and 20 (13%) did not. Severity of injury was significantly higher in the non-CT versus CT group patients. Observed mortality rate was significantly lower in the CT versus non-CT group (18% vs. 80%, P <0.001). Multivariate adjustment for the probability of survival (Ps) by TRISS method confirmed CT as an independent predictor for 28-day mortality (adjusted OR, 7.22; 95% CI, 1.76 to 29.60; P = 0.006). In the subgroup with less severe trauma (TRISS Ps ≥50%), SMR in the CT group was 0.63 (95% CI, 0.23 to 1.03; P = 0.066), indicating no significant difference between observed and predicted mortality in the CT group. In contrast, in the subgroup with more severe trauma (TRISS Ps <50%), SMR was 0.65 (95% CI, 0.41 to 0.90; P = 0.004) only in the CT group, whereas the difference between observed and predicted mortality was not significant in the non-CT group, suggesting a possible beneficial effect of CT on survival only in trauma patients at high risk of death. CONCLUSION: CT performed before emergency bleeding control might be associated with improved survival, especially in severe trauma patients with TRISS Ps of <50%.

Probiotic/synbiotic therapy for treating critically ill patients from a gut microbiota perspective.

The gut is an important target organ for stress caused by severe insults such as sepsis, trauma, burn, shock, bleeding and infection. Severe insult to the gut is considered to have an important role in promoting infectious complications and multiple organ dysfunction syndrome. These are sequelae of interactions between deteriorated intestinal epithelium, the immune system and commensal bacteria. The gut is the "motor" of multiple organ failure, and now it is recognized that gut dysfunction is a causative factor in disease progression. The gut flora and environment are significantly altered in critically ill patients, and the number of obligate anaerobes is associated with prognosis. Synbiotic therapy is a combination of probiotics and prebiotics. Probiotic, prebiotic and synbiotic treatment has been shown to be a promising therapy to maintain and repair the gut microbiota and gut environment. In the critically ill, such as major abdominal surgery, trauma and ICU patients, synbiotic therapy has been shown to significantly reduce septic complications. Further basic and clinical research would clarify the underlying mechanisms of the therapeutic effect of probiotic/synbiotic treatment and define the appropriate conditions for use.

Nonoperative catheter management for cervical necrotizing fasciitis with and without descending necrotizing mediastinitis.

OBJECTIVE: To evaluate the clinical utility of catheter drainage for cervical necrotizing fasciitis (CNF) with and without descending necrotizing mediastinitis (DNM). DESIGN: Retrospective analysis. SETTING: Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine. PATIENTS: Thirty-two patients with clinically and radiographically diagnosed CNF with and without DNM were included. INTERVENTIONS: Catheters were introduced into the infected space through the patients' necks under sonographic and x-ray fluoroscopic guidance. MAIN OUTCOME MEASURES: Treatments, clinical course, complications, and mortality were evaluated. RESULTS: Catheter drainage was successfully performed in all patients. The CNF was due to pharyngeal infection in 14 patients (44%) and dental infection in 14 other patients (44%). Mediastinal extension occurred in 14 patients (44%). Overall mortality was 3.1%; only 1 patient with DNM died due to Clostridium sepsis. Both pharyngeal origin and diabetes mellitus were significantly associated with the development of DNM. More intensive treatment is necessary for patients with CNF with DNM than for patients with CNF without DNM. CONCLUSION: Percutaneous catheter drainage may be used as an effective treatment for CNF with and without DNM.