Japanese Clinical Practice Guidelines for Rehabilitation in Critically Ill Patients 2023 (J-ReCIP 2023).

Providing standardized, high-quality rehabilitation for critically ill patients is a crucial issue. In 2017, the Japanese Society of Intensive Care Medicine (JSICM) promulgated the "Evidence-Based Expert Consensus for Early Rehabilitation in the Intensive Care Unit" to advocate for the early initiation of rehabilitations in Japanese intensive care settings. Building upon this seminal work, JSICM has recently conducted a rigorous systematic review utilizing the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. This endeavor resulted in the formulation of Clinical Practice Guidelines (CPGs), designed to elucidate best practices in early ICU rehabilitation. The primary objective of this guideline is to augment clinical understanding and thereby facilitate evidence-based decision-making, ultimately contributing to the enhancement of patient outcomes in critical care settings. No previous CPGs in the world has focused specifically on rehabilitation of critically ill patients, using the GRADE approach. Multidisciplinary collaboration is extremely important in rehabilitation. Thus, the CPGs were developed by 73 members of a Guideline Development Group consisting of a working group, a systematic review group, and an academic guideline promotion group, with the Committee for the Clinical Practice Guidelines of Early Mobilization and Rehabilitation in Intensive Care of the JSICM at its core. Many members contributed to the development of the guideline, including physicians and healthcare professionals with multiple and diverse specialties, as well as a person who had been patients in ICU. Based on discussions among the group members, eight important clinical areas of focus for this CPG were identified. Fourteen important clinical questions (CQs) were then developed for each area. The public was invited to comment twice, and the answers to the CQs were presented in the form of 10 GRADE recommendations and commentary on the four background questions. In addition, information for each CQ has been created as a visual clinical flow to ensure that the positioning of each CQ can be easily understood. We hope that the CPGs will be a useful tool in the rehabilitation of critically ill patients for multiple professions.

Characterization of recombinant photoconverting green fluorescent Akanes.

Akanes are fluorescent proteins that have several fluorescence maxima. In this report, Akane1 and Akane3 from Scleronephthya gracillima were selected, successfully overexpressed in Escherichia coli and purified by affinity chromatography. Fluorescence spectra of the recombinant Akanes matured in darkness, or ambient light were found to have several fluorescence peaks. SDS-PAGE analysis revealed that Akanes matured in ambient light have two fragments. MS/MS analysis of Akanes digested with trypsin showed that the cleavage site is the same as observed for the photoconvertible fluorescent protein Kaede. The differences between the calculated masses from the amino acid sequence of Akane1 and the measured masses of Akane1 fragments obtained under ambient light coincided with those of Kaede. In contrast, a mass difference between the measured N-terminal Akane3 fragment and the calculated mass indicated that Akane3 is modified in the N-terminal region. These results indicate that numerous peaks in the fluorescent spectra of Akanes partly arise from isoproteins of Akanes and photoconversion. Photoconversion of Akane1 caused a fluorescence change from green to red, which was also observed for Akane3; however, the fluorescent intensity decreased dramatically when compared with that of Akane3.

Change of pathotype and phylogenetic analysis of infectious bronchitis virus detected in Kagoshima prefecture, Japan.

Infectious bronchitis (IB) is a highly contagious disease in chickens, induced by IB virus (IBV) infection. The pathotype and S1 genotype of IBV field strain that was detected from 2008 to 2018 were investigated in Kagoshima prefecture, Japan. The frequency of cases that the renal lesion characteristic of IBV infection was histopathologically confirmed was significantly higher from 2014 to 2018 than from 2008 to 2009, suggesting the altered pathotype of IBV. Of 7 genotypes (JP-I, JP-II, JP-III, JP-IV, Mass, Gray, and 4/91) that have been detected in Japan, 6 genotypes except for JP-II were detected since 2008 and it appeared that the JP-III and JP-I have been predominant. The JP-IV with different antigenicity from other genotypes was detected since 2009.

Whole genome analysis of a novel neurotropic bovine astrovirus detected in a Japanese black steer with non-suppurative encephalomyelitis in Japan.

While neurotropic bovine astroviruses (BoAstVs) have been identified in North America and Europe, their presence has never been reported in Asia. In this study, we detected BoAstV in the brain of a steer showing neurological signs. Phylogenetic analysis revealed that the identified virus belongs to the Virginia/Human-Mink-Ovine clade, which contains most of the neurotropic astroviruses including the neurotropic BoAstVs. Similarity plot analysis showed that the virus was closely related to the American BoAstV NeuroS1 strain with respect to the ORF regions and to the European BoAstV CH13 strain in the 3' untranslated region, suggesting the occurrence of intra-genotypic recombination events.

[Significance of Multi-center Obstetrics Perioperative Team Training Including Various Medical Staffs].

We report the development of a multi-center/multispecialist obstetrics perioperative team training program. Participants were members of the team, including anesthesiologists, obstetricians, and operation nurses. A questionnaire survey was conducted prior to course participation to clarify any questions team members had. The courses included a lecture and simulation training with scenario-based discussions or the use of a simulator. Scenarios included massive bleeding during cesarean section, massive bleeding after vaginal delivery, and emergency cesarean section for premature placental abruption. After each course, participants discussed problems associated with obstetrics medical safety in the context of each theme. Simulation-based perioperative team training with anesthesiologists, obstetricians, and operation nurses may serve as a vehicle to promote perioperative obstetrics patient safety.

[Simulation-based Perioperative Team Training in the Operating Room].

Here, we report the development of a simulation-based perioperative training course. Participants were anesthesiologists and operating room nurses. Three different courses were held with different themes, such as airway management, circulation management and central venous management. The courses included a lecture and simulation training with scenario-based discussions or a simulator. At the end of each course, participants discussed problems associated with medical safety in the context of each theme. Participants commented not only on changes in their views regarding individual technical or non-technical improvements, but also on general medical safety in the operating room. Our findings suggest that simulation-based perioperative team training may serve as a vehicle to promote operating room safety.

[Development and Hosting of a Perioperative Advanced Life Support Training Course for Anesthesiologists].

Participation in the American Heart Association advanced cardiac life support provider course is a prerequisite for taking the anesthesiology specialist examination in Japan. The course teaches fundamental resuscitation methods for different types of cardiac arrest. However, crisis in the perioperative period can result from airway trouble, central venous catheter displacement, or massive hemorrhage. We report our experience of holding a problem- and learning-based perioperative advanced life support training course, Advanced Life Support for Operation (ALS-OP). Main contents of the course included circulation management, airway management central venous catheters, and pain clinic-related complications. ALS-OP simulation training may be beneficial for educating anesthesiologist and promoting perioperative patient safety.

Comparison of Pentax-AWS Airwayscope and Glidescope for Infant Tracheal Intubation by Anesthesiologists during Cardiopulmonary Arrest Simulation: A Randomized Crossover Trial.

BACKGROUND: Recent guidelines for infant cardiopulmonary resuscitation emphasize that all rescuers should minimize interruption of chest compressions, even for endotracheal intubation. We compared the utility of the Pentax-AWS Airwayscope (AWS) with the Glidescope (GS) during chest compressions on an infant manikin. METHODS: Twenty-four anesthesiologists with more than two years of experience performed tracheal intubation on an infant manikin using the AWS and GS, with or without chest compressions. RESULTS: In GS trials, none of the participants failed without compressions, while three failed with compressions. In AWS trials, all participants succeeded regardless of chest compressions. Intubation time was significantly longer with chest compressions with the GS (P < 0.05), but not with the AWS. Difficulty of operation on a visual analog scale (VAS) for laryngoscopy did not increase significantly with chest compressions with either the GS or the AWS, while the VAS for tube passage through the glottis increased with compressions with the GS, but not with the AWS. CONCLUSION: We conclude that in infant simulations managed by anesthesiologists, the AWS performed better than the GS for endotracheal intubation with chest compressions.

Comparison of tube-guided and guideless videolaryngoscope for tracheal intubation during chest compression in a manikin: a randomized crossover trial.

BACKGROUND: Previous studies have shown the utility of indirect glottis viewing videolaryngoscopes for tracheal intubation during chest compression, but the efficacy of a videolaryngoscope with tube guide has not been sufficiently validated. We compared the utility of two videolaryngoscopes, the KingVISION(®) (KingV) with or without tube guide blade and Pentax-AWS Airwayscope(®) (AWS), which contain tube guide function, during chest compressions on an adult manikin. METHODS: Twenty-five novice doctors and 22 experienced anesthesiologists performed tracheal intubation on an adult manikin using the AWS and KingV with or without chest compressions. The KingV trials were performed either with a tube guide 'channeled blade' (KingV-Guided) or without, using a 'standard blade' (KingV-Guideless). RESULTS: In the KingV-Guideless trial, all novice doctors successfully secured the airway without chest compressions but seven failed with chest compressions (p < 0.05), while no experienced doctors failed without chest compression and two did during chest compression. In the AWS and KingV-Guided trials, all participants succeeded both with and without chest compressions performed by both novice doctors and experienced anesthesiologists. Intubation time was lengthened significantly by chest compressions in the KingV-Guideless trial (p < 0.05), but not in the AWS or KingV-Guided trials performed by both novice doctors and experienced anesthesiologists. The intubation time for KingV-Guided during chest compression was significantly smaller by experienced anesthesiologists compared to by novice doctors. CONCLUSIONS: These findings suggest that the AWS and KingV-Guided devices are more effective than the KingV-Guideless for airway management with chest compressions in adult simulations, especially performed by novice doctors. The tube guide function may contribute to successful airway management during chest compression by the added videolaryngoscopy function.

A case of incomplete Carney's triad.

A 62-year-old woman, who had multiple pulmonary nodules noted 6 years earlier, and surgery for a gastrointestinal stromal tumor 2 years earlier, was found to have enlargement of her pulmonary nodules. Surgery was selected to make a definite diagnosis. Thoracoscopic segmentectomy of right segments 9 and 10 was performed, and pulmonary chondroma was diagnosed. Carney designated the combination of 3 rare soft tissue tumors (gastric leiomyosarcoma, pulmonary chondroma, and extraadrenal paraganglioma) as a syndrome. This patient may have had an incomplete type of Carney's triad with 2 lesions in the stomach and lung.

Intramuscular myxoma in the chest wall.

Intramuscular myxomas are benign soft-tissue tumors that often develop in the thigh. A 66-year-old woman was referred with an abnormal shadow on chest roentgenogram. The tumor was well defined and smooth and originated from the second intercostal space. Positron emission tomography showed no accumulation of 18F-fluorodeoxyglucose in the tumor. The patient attended the outpatient department for follow-up care. Because the mass grew slightly after 52 months, the patient underwent complete removal by video-assisted thoracoscopic surgery. On histopathological examination, the tumor was diagnosed as an intramuscular myxoma in the chest wall. The patient has had no recurrence 3 years after surgery. A case of intramuscular myxoma in the chest wall, completely resected by video-assisted thoracoscopic surgery, is reported. A well-defined, smooth, homogeneous mass in the chest wall may therefore be intramuscular myxoma.

A practical prediction model for early hematoma expansion in spontaneous deep ganglionic intracerebral hemorrhage.

OBJECTIVE: Early hematoma expansion is a known cause of morbidity and mortality in patients with intracerebral hemorrhage (ICH). The goal of this study was to identify clinical predictors of ICH growth in the acute stage. MATERIALS AND METHODS: We studied 201 patients with acute (<6 h) deep ganglionic ICH. Patients underwent CT scan at baseline and hematoma expansion (>33% or >12.5 ml increase) was determined on the second scan performed within 24 h. Fourteen clinical and neuroimaging variables (age, gender, GCS at admission, hypertension, diabetes mellitus, kidney disease, stroke, hemorrhagic, antiplatelet use, anticoagulant use, hematoma density heterogeneity, hematoma shape irregularity, hematoma volume and presence of IVH) were registered. Additionally, blood pressure was registered at initial systolic BP (i-SBP) and systolic BP 1.5 h after admission (1.5 h-SBP). The discriminant value of the hematoma volume and 1.5 h-SBP for hematoma expansion were determined by the receiver operating characteristic (ROC) curves. Factors associated with hematoma expansion were analyzed with multiple logistic regression. RESULTS: Early hematoma expansion occurred in 15 patients (7.0%). The cut-off value of hematoma volume and 1.5 h-SBP were determined to be 16 ml and 160 mmHg, respectively. Hematoma volume above 16 ml (HV>16) ([OR]=5.05, 95% CI 1.32-21.36, p=0.018), hematoma heterogeneity (HH) ([OR]=7.81, 95% CI 1.91-40.23, p=0.004) and 1.5 h-SBP above 160 mmHg (1.5 h-SBP>160) ([OR]=8.77, 95% CI 2.33-44.56, p=0.001) independently predicted ICH expansion. If those three factors were present, the probability was estimated to be 59%. CONCLUSIONS: The presented model (HV>16, HH, 1.5 h-SBP>160) can be a practical tool for prediction of ICH growth in the acute stage. Further prospective studies are warranted to validate the ability of this model to predict clinical outcome.

A case of coelomic cysts of the mediastinum.

Coelomic cysts are rare cysts of mesothelial origin. They are generally unilocular and can develop in various sites. We describe a case of a multicystic lesion discovered incidentally in the anterior mediastinum of a 41-year-old man. Immunohistochemistry confirmed multiple coelomic cysts of the mediastinum.

Serum hepatocyte growth factor and interleukin-6 are effective prognostic markers for non-small cell lung cancer.

AIM: We surveyed prognostic biomarkers for resectable non-small cell lung cancer (NSCLC). PATIENTS AND METHODS: We obtained preoperative serum from 109 patients, and measured the levels of hepatocyte growth factor (HGF), interleukin-6 (IL-6), and nicotinamide N-methytransferase (NNMT) in the sera. RESULTS: The median HGF and IL-6 contents were 860 pg/ml and 2.7 pg/ml, respectively. Analysis of survival curves indicated that an HGF or IL-6 level higher than the median was associated with poor overall survival (HGF, p=0.019; IL-6, p=0.002). In addition, we analyzed stage III lung cancer alone. Higher HGF and IL-6 levels were associated with poor overall survival (HGF, p=0.016; IL-6, p=0.013). Disease-free survival was not statistically significantly affected by these cytokine contents. The tumor status (pT factor) and nodal status (pN factor) were not associated with the survival of stage III patients. CONCLUSION: The levels of HGF and IL-6 in serum could be useful prognostic indicators of the survival of patients with stage III NSCLC undergoing surgery and chemotherapy.

A case of primary solitary pulmonary plasmacytoma.

Most solitary extramedullary plasmacytomas are plasma cell tumors that tend to develop in mucosa-associated lymphoid tissues including the upper respiratory tract. We present a 43-year-old patient who was diagnosed with a solitary plasmacytoma in the lung. Primary plasmacytoma of the lung is exceedingly rare, and the treatment is surgical excision. This malignancy advances to multiple myeloma in a minority of patients. Multiple myeloma is a plasma cell malignancy that typically presents in the bone marrow.

Venous hemangioma of the posterior mediastinum.

Here, we describe our experience in treating a patient with mediastinal hemangioma, a rare neoplasm. An abnormal shadow was noted in the thoracic region of a 54-year-old woman at a health checkup, and she was referred to our hospital. A neurogenic tumor was suspected based on the findings of the chest X-ray and computed tomography scan. Thoracoscopic tumorectomy was performed. The tumor surface was smooth with a reddish-dark reddish color, and capillary blood vessels showed marked growth around the tumor. The tumor was composed of medium or large blood vessels with a relatively thick vascular wall containing smooth muscle. On immunostaining, anti-CD34 antibody and Factor VIII were positive and D2-40 was negative. Based on these findings, the tumor was diagnosed as mediastinal venous hemangioma.

Characteristics and prognostic value of acute catecholamine surge in patients with aneurysmal subarachnoid hemorrhage.

OBJECTIVES: The characteristics of serum catecholamine concentration at the hyper-acute phase of aneurysmal subarachnoid hemorrhage (SAH) and its relationship between patient outcome and delayed vasospasm were investigated. METHODS: Patients with aneurysmal SAH (170) were prospectively studied between August 2008 and June 2011. Baseline demographic data and physiological parameters, including plasma concentrations of adrenaline (AD), noradrenaline (NA), and dopamine (DP) were evaluated for all patients. RESULTS: On admission, plasma AD, NA, and DP levels were significantly higher in patients with a poor clinical grade on admission (Hunt and Kosnik grade: IV-V), compared to those with a good clinical grade on admission (Hunt and Kosnik grade: I-III). AD showed a markedly high concentration immediately after the onset of SAH and then rapidly decreased. NA levels peaked within 6 hours after onset, then significantly decreased. The increase of DP with time was not significant, but showed a similar trend to that of NA. The level of each catecholamine showed significant mutual correlation. Our multivariate model demonstrated that age, poor clinical grade at admission, plasma AD and NA levels were good predictors of poor patient outcome [receiver operating characteristic (ROC) area: 0.83]. And that poor clinical grade at admission, Fisher scale, blood sugar level and plasma AD level were good predictors of the development of delayed vasospasm (ROC area: 0.81) (1.3). CONCLUSIONS: The present findings suggest that sympathetic activation in patients in the acute phase of SAH reflects the severity of SAH, and is closely related to the development of delayed vasospasm, leading to the subsequent immune response and inflammatory reactions. Strategies for suppressing catecholamine at the hyper-acute phase may contribute to vasospasm prevention and improve patient outcome.

Unification of T2a and T2b tumors to T2 tumors in non-small cell lung cancer staging.

INTRODUCTION: We investigated the validation of the seventh edition of the TNM staging (2009) system for lung cancer, retrospectively. METHODS: From January 1990 to March 2004, 1629 patients who underwent lung resection with systemic lymph node dissection for non-small cell lung cancer at Nippon Medical School and Saitama Cancer Center were included. The overall survivals after surgery by each pathological stage according to the 1997 and 2009 systems were statistically analyzed using Kaplan-Meier estimated survival curves, and the significance of the difference was analyzed by the log-rank test. RESULTS: The 2009 system had significant prognostic distinction between each T descriptor except for T2a and T2b, and between each M descriptor. The 2009 system had better prognostic distinction between each pathological stage except for stages IB and IIA, and stages IIIB and IV. In the simulation, we unified T2a and T2b tumors into T2 tumors, and T2bN0M0 and T2bN1M0 were moved to stages IB and IIA, respectively. This proposed system had significant prognostic distinction between the proposed IB, IIA, and IIB stages. CONCLUSIONS: The 2009 system provides better patient selection for surgery and prognostic distinction between each stage except for stages IB and IIA, and stages IIIB and IV, compared with the 1997 system. Unification of T2a and T2b tumors to T2 tumors can improve prognostic distinction between stages IB and IIA.