Fusion Growth and Extraordinary Distortion of Ultrasmall Metal Oxide Nanoparticles.

Ultrasmall metal oxide nanoparticles (<5 nm) potentially have new properties, different from conventional nanoparticles. The precise size control of ultrasmall nanoparticles remains difficult for metal oxide. In this study, the size of CeO2 nanoparticles was precisely controlled (1.3-9.4 nm) using a continuous-flow hydrothermal reactor, and the atomic distortion that occurs in ultrasmall metal oxides was explored for CeO2. The crystalline nanoparticles grow rapidly like droplets via coalescence, although they reach a critical particle size (∼3 to 4 nm), beyond which they grow slowly and change shape through ripening. In the initial growth stage, the ultrasmall nanoparticles exhibit disordered atomic configurations, including stacking faults. In ultrasmall CeO2 nanoparticles (<3 to 4 nm), unusual electron localization occurs on Ce 4f orbitals (Ce3+) as a result of O disordering, regardless of O vacancy concentration. This behavior differs from ordinary electron localization caused by the presence of O vacancies. The ultrasmall metal oxides have extraordinary distortion states, making them promising for use in nanotechnology applications. Furthermore, the proposed synthesis method can be applied to various other metal oxides and allows exploration of their properties.

Early detection of necrosis in low-enhanced pancreatic parenchyma using contrast-enhanced computed tomography was a better predictor of clinical outcomes than pancreatic inflammation: A multicentric cohort study of severe acute pancreatitis.

OBJECTIVES: We aim to assess the early use of contrast-enhanced computed tomography (CECT) of patients with severe acute pancreatitis (SAP) using the computed tomography severity index (CTSI) in prognosis prediction. The CTSI combines quantification of pancreatic and extrapancreatic inflammation with the extent of pancreatic necrosis. METHODS: Post-hoc retrospective analysis of a large, multicentric database (44 institutions) of SAP patients in Japan. The area under the curve (AUC) of the CTSI for predicting mortality and the odds ratio (OR) of the extent of pancreatic inflammation and necrosis were calculated using multivariable analysis. RESULTS: In total, 1097 patients were included. The AUC of the CTSI for mortality was 0.65 (95 % confidence interval [CI:] [0.59-0.70]; p < 0.001). In multivariable analysis, necrosis 30-50 % and >50 % in low-enhanced pancreatic parenchyma (LEPP) was independently associated with a significant increase in mortality, with OR 2.04 and 95 % CI 1.01-4.12 (P < 0.05) and OR 3.88 and 95 % CI 2.04-7.40 (P < 0.001), respectively. However, the extent of pancreatic inflammation was not associated with mortality, regardless of severity. CONCLUSIONS: The degree of necrosis in LEPP assessed using early CECT of SAP was a better predictor of mortality than the extent of pancreatic inflammation.

Clinical significance of reactive thrombocytosis in the course of acute pancreatitis.

BACKGROUND: Reactive thrombocytosis occurs secondary to systemic infections, inflammatory, and other conditions. The relationship between thrombocytosis and acute pancreatitis (AP) in inflammatory diseases is uncertain. This study aimed to evaluate the clinical significance of thrombocytosis in AP patients during hospitalization. METHODS: Subjects within 48 h of AP onset were consecutively enrolled over 6 years. Platelet counts of ≥ 450,000/µL were defined as thrombocytosis, < 100,000/µL as thrombocytopenia, and other counts as normal. We compared clinical characteristics, including the rate of severe AP (SAP) assessed by the Japanese Severity Score; blood markers, including hematologic and inflammatory factors and pancreatic enzymes during hospitalization; and pancreatic complications and outcomes in the three groups. RESULTS: A total of 108 patients were enrolled. Although, SAP was more common in patients with thrombocytosis and thrombocytopenia (87.9% and 100%, respectively), the differences in lymphocytes and C-reactive protein, lactase dehydrogenase, and antithrombin levels, which are factors of the systemic inflammatory response, and the mean platelet volume, an indicator of platelet activation, were observed among patients with thrombocytosis and thrombocytopenia during hospitalization. Regarding pancreatic complications and outcomes, patients with thrombocytosis and thrombocytopenia had higher acute necrotic collection (ANC), pancreatic necrosis, intestinal paralysis, respiratory dysfunction, and pancreatic-related infection levels than patients with normal platelet levels. The relationship between pancreatic complications and thrombocytosis was assessed by multivariate logistic regression; the odds ratios for development of ANC, pancreatic necrosis and pancreatic-related infections were 7.360, 3.735 and 9.815, respectively. CONCLUSIONS: Thrombocytosis during hospitalization for AP suggests development of local pancreatic complications and pancreatic-related infections.

Elevated INR in a COVID-19 patient after concomitant administration of favipiravir and warfarin: A case report.

WHAT IS KNOWN AND OBJECTIVE: Favipiravir is a promising treatment candidate for managing coronavirus disease 2019 (COVID-19). Warfarin has many drug interactions, but no interactions with favipiravir have been reported. CASE SUMMARY: Our patient was taking warfarin for deep vein thrombosis. The international normalized ratio (INR) was stable (1.65 to 2.0); however, it increased to 4.63 after administering favipiravir. The patient had no other factors justifying this change. WHAT IS NEW AND CONCLUSION: Favipiravir and warfarin might have previously unidentified drug interactions that elevated the INR. Therefore, INR must be closely monitored when they are concomitantly administered in COVID-19 patients.

Etiology and mortality in severe acute pancreatitis: A multicenter study in Japan.

BACKGROUND/OBJECTIVES: Severe acute pancreatitis (SAP) has a high mortality rate despite ongoing attempts to improve prognosis through a various therapeutic modalities. This study aimed to delineate etiology-based routes that may guide clinical decisions for the treatment of SAP. METHODS: Using data from a recent retrospective multicenter study in Japan, we analyzed the association between clinical outcomes, mainly in-hospital mortality and pancreatic infection, and various etiologies while considering confounding factors. We performed additional multivariate analyses and built decision tree models. RESULTS: The 1097 participating patients were classified into the following groups by etiology: alcohol (n = 436, 39.7%); cholelithiasis (n = 230, 21.0%); idiopathic (n = 227, 20.7%); and others (n = 204, 18.6%). Mortality at hospital discharge was 8.4%, 12.2%, 16.7%, and 16.2% in the alcohol, cholelithiasis, idiopathic, and others groups, respectively. According to multivariable analysis, early enteral nutrition (EN) was significantly associated with reduced in-hospital mortality only in the cholelithiasis group. However, there was a consistent association between age and the need for mechanical ventilation and increased mortality, regardless of etiology. Our decision tree models presented different contributing factors depending on the etiology and patient background. Interaction analysis showed that EN and the use of prophylactic antibiotics may influence these results differently according to etiology. CONCLUSIONS: No study has yet used comprehensive models to investigate etiology-related prognostic factors for SAP; our results can, therefore, be used as a reference for improving clinical decisions.

Usefulness of a New Device to Monitor Cerebral Blood Oxygenation Using NIRS During Cardiopulmonary Resuscitation in Patients with Cardiac Arrest: A Pilot Study.

Recent guidelines on cardiopulmonary resuscitation (CPR) have stressed the necessity to improve the quality of CPR. Our previous studies demonstrated the usefulness of monitoring cerebral blood oxygenation (CBO) during CPR by near-infrared spectroscopy (NIRS). The present study evaluates whether the NIRO-CCR1, a new NIRS device, is as useful in the clinical setting as the NIRO-200NX. We monitored CBO in 20 patients with cardiac arrest by NIRS. On the arrival of patients at the emergency department, the attending physician immediately assessed whether the patient was eligible for this study after conventional advanced life support and, if eligible, measured CBO in the frontal lobe by NIRS. We found that in all patients, the cerebral blood flow waveform was in synchrony with the chest compressions. Moreover, the tissue oxygenation index increased following cardiopulmonary bypass (CPB) in patients undergoing CPB, including one patient in whom CBO was monitored using the NIRO-CCR1. In addition, although the NIRO-CCR1 could display the pulse rate (Tempo) in real time, Tempo was not always detected, despite detection of the cerebral blood flow waveform. This suggested that chest compressions may not have been effective, indicating that the NIRO-CCR1 also seems useful to assess the quality of CPR. This study suggests that the NIRO-CCR1 can measure CBO during CPR in patients with cardiac arrest as effectively as the NIRO-200NX; in addition, the new NIRO-CCR1 may be even more useful, especially in prehospital fields (e.g. in an ambulance), since it is easy to carry.

Large Volume Fluid Resuscitation for Severe Acute Pancreatitis is Associated With Reduced Mortality: A Multicenter Retrospective Study.

BACKGROUND AND AIMS: Although fluid resuscitation is critical in acute pancreatitis, the optimal fluid volume is unknown. The aim of this study is to evaluate the association between the volume of fluid administered and clinical outcomes in patients with severe acute pancreatitis (SAP). METHODS: We conducted a multicenter retrospective study at 44 institutions in Japan. Inclusion criteria were age 18 years or older, and diagnosed with SAP from 2009 to 2013. Patients were stratified into 2 groups: administered fluid volume <6000 and ≥6000 mL in the first 24 hours. We evaluated the association between the 2 groups and clinical outcomes using multivariable logistic regression analysis. The primary outcome was in-hospital mortality. Secondary outcomes included the incidence of pancreatic infection and the need for surgical intervention. RESULTS: We analyzed 1097 patients, and the mean fluid volume administered was 5618±3018 mL (mean±SD), with 708 and 389 patients stratified into the fluid <6000 mL and fluid ≥6000 mL groups, respectively. Overall in-hospital mortality was 12.3%. The fluid ≥6000 mL group had significantly higher mortality than the fluid <6000 mL group (univariable analysis, 15.9% vs. 10.3%; P<0.05). In multivariable logistic regression analysis, administration of ≥6000 mL of fluid within the first 24 hours was significantly associated with reduced mortality (odds ratio, 0.58; P<0.05). No significant association was found between the administered fluid volume and pancreatic infection, or between the volume administered and the need for surgical intervention. CONCLUSIONS: In patients with SAP, administration of a large fluid volume within the first 24 hours is associated with decreased mortality.

Systemic impact on secondary brain aggravation due to ischemia/reperfusion injury in post-cardiac arrest syndrome: a prospective observational study using high-mobility group box 1 protein.

BACKGROUND: Ischemia/reperfusion injury (I/R) is an important pathophysiology of post-cardiac arrest syndrome (PCAS) against multiple organ dysfunction and mortality. The inflammatory response in PCAS causes systemic I/R. The purpose of this study was to demonstrate the pathophysiology of systemic I/R for secondary brain damage using the biomarkers high-mobility group box 1 (HMGB1), neuron-specific enolase (NSE), and interleukin-6 (IL-6). METHODS: This study was designed as a single-institution prospective observational study. Subjects were observed for 90 days, and neurological outcome was classified according to the Glasgow-Pittsburgh Cerebral Performance Categories Scale (CPC). Serum HMGB1, NSE, and IL-6 were evaluated for variability, correlation with each biomarker, or the Sequential Organ Function Assessment (SOFA) score and CPC at return of spontaneous circulation at 0, 24, 48, and 168 h. RESULTS: A total of 128 patients were enrolled in this study. Initial HMGB1 correlated with CPC (ρ = 0.27, p = 0.036) and SOFA score (ρ = 0.33, p < 0.001). The early phase of HMGB1 (0-24 h), all phases of IL-6, and the delayed phase of NSE (24-168 h) manifested poor neurological outcome. HMGB1 showed a significant correlation with NSE (ρ = 0.29, p = 0.002 at 0 h; ρ = 0.42, p < 0.001 at 24 h) and IL-6 (ρ = 0.36, p < 0.001 at 24 h). CONCLUSIONS: Serum HMGB1 for first 24 h after cardiac arrest was significantly correlated with SOFA score, NSE, and IL-6. This result suggests that systemic I/R may contribute to secondary brain aggravation. It is expected that research on HMGB1 focused on systemic I/R will help prevent aggravating neurological outcomes.

Detection of ROSC in Patients with Cardiac Arrest During Chest Compression Using NIRS: A Pilot Study.

Return of spontaneous circulation (ROSC) during chest compression is generally detected by arterial pulse palpation and end-tidal CO2 monitoring; however, it is necessary to stop chest compression during pulse palpation, and to perform endotracheal intubation for monitoring end-tidal CO2. In the present study, we evaluated whether near-infrared spectroscopy (NIRS) allows the detection of ROSC during chest compression without interruption. We monitored cerebral blood oxygenation in 19 patients with cardiac arrest using NIRS (NIRO-200NX, Hamamatsu Photonics, Japan). On arrival at the emergency room, the attending physicians immediately assessed whether a patient was eligible for this study after conventional advanced life support (ALS) and employed NIRS to measure cerebral blood oxygenation (CBO) in the bilateral frontal lobe in patients. We found cerebral blood flow waveforms in synchrony with chest compressions in all patients. In addition, we observed abrupt increases of oxy-hemoglobin concentration and tissue oxygen index (TOI), which were associated with ROSC detected by pulse palpation. The present findings indicate that NIRS can be used to assess the quality of chest compression in patients with cardiac arrest as demonstrated by the detection of synchronous waveforms during cardiopulmonary resuscitation (CPR). NIRS appears to be applicable for detection of ROSC without interruption of chest compression and without endotracheal intubation.

Patients with Severe Trauma Having an Injury Severity Score of 24 and above Develop Nutritional Disorders.

In this single-center, retrospective, observational study, we aimed to assess the severity at which patients with trauma tend to develop metabolic disturbances that worsen their Controlling Nutritional Status (CONUT) scores. Participants were general adult patients with trauma hospitalized for at least one week. Injury Severity Scores (ISSs) at admission and CONUT scores one week later were calculated, and correlation coefficients were examined. The receiver operating characteristic (ROC) curve was used to calculate the ISS cutoff value for a CONUT score of 5 or more on day 7 of hospitalization. The ISS was assessed using multiple logistic regression analysis to determine whether it predicts worse nutritional status. Forty-nine patients were included. ISSs correlated with CONUT scores on day 7 (r = 0.373, p = 0.008). Using the ROC curve, the cutoff value for the ISS was 23.5. Multiple logistic regression analyses showed that a high ISS (odds ratio [OR], 1.158; 95% confidence interval [CI], 1.034-1.296; p = 0.011) and older age (OR, 1.094; 95% CI, 1.027-1.165; p = 0.005) were associated with a CONUT score 5 or more on day 7 of hospitalization. Patients with trauma with an ISS of 24 or higher have worsening CONUT scores during hospitalization; these patients require careful nutritional management.

Administration of Intravenous Lipid Emulsion for Dextromethorphan Poisoning with Serotonin Syndrome: A Case Report.

Dextromethorphan (DXM) is used to treat colds and coughs; however, it can cause central nervous system symptoms, such as severe serotonin syndrome (SS). To our knowledge, there is no specific treatment for severe DXM poisoning, and there are no reports on the clinical use of intravenous lipid emulsion (ILE) for its treatment. Herein, we report a case of severe DXM poisoning with SS that was successfully treated with ILE. An older adolescent male visited the emergency department 1 h after ingesting 4500 mg of DXM orally. Physical examination revealed generalized convulsions, muscle rigidity, mydriasis (8.0/8.0 mm), and flushed skin, with a Glasgow Coma Scale score of 8 (E3V1M4). Severe DXM poisoning with SS was diagnosed. The patient was intubated and administered midazolam for continuous convulsions and SS. Activated charcoal was also administered, and body surface cooling was performed. After an 11 h intensive care unit admission, SS with mydriasis (6.0/6.0 mm) did not improve. Subsequently, 1100 mL of 20% soybean oil was injected as an ILE. Mydriasis improved (3.5/3.5 mm) 30 min after ILE administration; simultaneously, blood DXM concentration rapidly increased approximately two-fold. After discontinuing midazolam, the patient's consciousness signs improved, and he was weaned off the ventilator. SS was cured with no recurrence of convulsions. In cases of DXM poisoning with severe central nervous system disorders, such as SS, ILE treatment can potentially be an effective therapeutic option. For oral overdose cases, where the drug may remain in the intestinal tract, measures such as administering activated charcoal should be taken before administering ILE.

Usefulness of the hybrid technique of interventional radiology and endoscopic treatment for intestinal bleeding after pancreaticoduodenectomy: a case report.

Introduction and importance: In endovascular treatment of ruptured pseudoaneurysm after pancreaticoduodenectomy (PD) with gastrointestinal bleeding, treatment for vasospasm of the culprit vessel from haemorrhagic shock and subsequent reperfusion has not been determined before. Case presentation: The authors hereby present you with a case of a 59-year-old man with unknown operative method upon arrival at the Emergecy room and who had hematemesis and collapse 6 months post-PD surgery. Clinical discussion: An initial contrast-enhanced computed tomography (CT) revealed no obvious source of bleeding, so an upper gastrointestinal endoscope was performed. Rebleeding occurred during the examination, and interventional radiology was performed because haemostasis was difficult. Coil embolization was performed for leakage of contrast material from the gastroduodenal artery stump into the gastrointestinal tract. However, because the embolization was uncertain due to vasospasm of the common hepatic artery, endoscopic clipping of the perforation site was also performed to prevent rebleeding due to reperfusion after improvement of vasospasm. A CT scan 5 days later showed reperfusion of the coil-implanted vessel. No rebleeding or hepatic infarction occurred postoperatively. Conclusion: In this case, the haemostasis by coil embolization was uncertain due to the presence of vasospasm, and clipping was used in combination with the procedure to prevent rebleeding.

Changes of cerebral oxygen metabolism and hemodynamics during ECPR with hypothermia measured by near-infrared spectroscopy: a pilot study.

BACKGROUND: The 2010 CPR Guidelines recommend that extracorporeal cardiopulmonary resuscitation (ECPR) using an emergency cardiopulmonary bypass (CPB) should be considered for patients with cardiac arrest. However, it is not yet clear whether this therapy can improve cerebral circulation and oxygenation in these patients. To clarify this issue, we evaluated changes of cerebral blood oxygenation (CBO) during ECPR using near-infrared spectroscopy (NIRS). METHODS: We employed NIRS to measure CBO in the bilateral frontal lobe in patients transported to the emergency room (ER) after out-of-hospital cardiac arrest between November 2009 and June 2011. RESULTS: Fifteen patients met the above criteria. The tissue oxygenation index (TOI) on arrival at the ER was 36.5 %. This increased to 67.8 % during ECPR (P < 0.001). The one patient whose TOI subsequently decreased had a favorable neurological outcome. CONCLUSION: Increase of TOI during ECPR might reflect an improvement in cerebral blood flow, while decrease of TOI after ECPR might reflect oxygen utilization by the brain tissue as a result of neuronal cell survival. NIRS may be useful for monitoring cerebral hemodynamics and oxygen metabolism during CPR.

Impaired consciousness and unilateral limb movement due to acute limb ischemia complicated by acute cerebral infarction: A case report.

RATIONALE: The symptoms of impaired consciousness and unilateral motor impairments are a perfect scenario for cerebral infarction, and a physician can easily miss the findings of limb ischemia on the patient paralyzed side even if acute limb ischemia (ALI) occurs on that side. The purpose of this case report is to reiterate the need to suspect ALI in patients with impaired consciousness who cannot complain of symptoms such as abnormal limb paresthesia or pain. PATIENT CONCERNS: An 89-year-old woman with impaired consciousness and motor impairment of the left upper and lower extremities was transported to our hospital. DIAGNOSES: Brain magnetic resonance imaging showed a suspected cerebral infarction in the posterior circulation; contrast-enhanced computed tomography showed occlusion of the left axillary artery and left femoral artery; and ultrasonography showed occlusion of the right popliteal artery. INTERVENTIONS: Cerebral angiography was performed simultaneously with surgical thrombectomy to treat the ALI. Mechanical thrombectomy was not performed for cerebral infarction. OUTCOMES: Although motor impairment of the left upper and lower extremities persisted, the patient successfully underwent limb salvage. LESSONS: Both cerebral infarction and ALI require early diagnosis and treatment. This rare case of cerebral infarction complicated by ALI emphasizes the need to avoid missing the signs of ALI in patients with impaired consciousness.

Successful Therapeutic Hypothermia in a Patient with Drug-Induced J Waves and Cardiac Arrest: A Case Report.

A 50-year-old man was admitted to our hospital with hypotension and bradycardia after receiving high doses of atenolol, amlodipine, and etizolam. He had a drug-induced J wave on electrocardiography and subsequently underwent cardiac arrest. The patient was successfully rescued by venoarterial extracorporeal membrane oxygenation (VA-ECMO) and a good neurological outcome was achieved with therapeutic hypothermia (TH). In patients with J waves, TH is thought to increase the J waves and cause fatal arrhythmias, but in this case, rapid cooling with VA-ECMO allowed the patient to successfully complete TH.

Beneficial effects of dantrolene in the treatment of rhabdomyolysis as a potential late complication associated with COVID-19: a case report.

BACKGROUND: Patients with severe COVID-19 have disorders of the respiratory, cardiovascular, coagulation, skeletal muscle, and central nervous systems. These systemic failures may be associated with cytokine release syndrome, characterized by hyperpyrexia, thrombocytopenia, hyperferritinemia, and the elevation of other inflammatory markers. Rhabdomyolysis with high fever is a complication that is rarely found in COVID-19. The exact relations of these clinical conditions in patients with COVID-19 remain unknown. CASE PRESENTATION: We present the case of a 36-year-old man with severe COVID-19 complicated by rhabdomyolysis and high fever. After admission, his condition continued to deteriorate, with a high body temperature. On day 9, the patient had elevated creatine kinase and myoglobin levels consistent with rhabdomyolysis (26,046 U/L and 3668 ng/mL, respectively). In addition to viral therapy, he was immediately treated with hydration. However, the patient had persistent fever and elevated creatine kinase levels. The patient was diagnosed with malignant hyperthermia as a late complication of COVID-19, although he had no hereditary predisposition to malignant hyperthermia or neuroleptic malignant syndrome. The administration of dantrolene with muscle relaxation and anti-inflammatory function showed potential efficacy for rhabdomyolysis, high fever, and increased plasma inflammatory markers. CONCLUSIONS: Malignant hyperthermia is triggered by not only anesthetic agents but also viral infections. A possible mechanism of malignant hyperthermia is hypersensitivity of calcium release from the sarcoplasmic reticulum. These include mutations in or the activation of the skeletal muscle ryanodine receptor calcium release channel. Dantrolene is a ryanodine receptor antagonist and is used as an anti-inflammatory agent. The administration of dantrolene showed potential efficacy for rhabdomyolysis, high body temperature due to inflammation, and increased inflammatory markers. The underlying mechanism of the association of rhabdomyolysis and high fever in COVID-19 might be similar to the pathogenesis of malignant hyperthermia.

Treatment With Vasopressor Agents for Cardiovascular Shock Patients With Poor Renal Function; Results From the Japanese Circulation Society Cardiovascular Shock Registry.

According to the guidelines for cardiogenic shock, norepinephrine is associated with fewer arrhythmias than dopamine and may be the better first-line vasopressor agent. This study aimed to evaluate the utility of norepinephrine vs. dopamine as first-line vasopressor agent for cardiovascular shock depending on the presence and severity of renal dysfunction at hospitalization. This was a secondary analysis of the prospective, multicenter Japanese Circulation Society Cardiovascular Shock Registry (JCS Shock Registry) conducted between 2012 and 2014, which included patients with shock complicating emergency cardiovascular disease at hospital arrival. The analysis included 240 adult patients treated with norepinephrine alone (n = 98) or dopamine alone (n = 142) as the first-line vasopressor agent. Primary endpoint was mortality at 30 days after hospital arrival. The two groups had similar baseline characteristics, including estimated glomerular filtration rate (eGFR), and similar 30-day mortality rates. The analysis of the relationship between 30-day mortality rate after hospital arrival and vasopressor agent used in patients categorized according to the eGFR-based chronic kidney disease classification revealed that norepinephrine as the first-line vasopressor agent might be associated with better prognosis of cardiovascular shock in patients with mildly compromised renal function at admission (0.0 vs. 22.6%; P = 0.010) and that dopamine as the first-line vasopressor agent might be beneficial for cardiovascular shock in patients with severely compromised renal function [odds ratio; 0.22 (95% confidence interval 0.05-0.88; P = 0.032)]. Choice of first-line vasopressor agent should be based on renal function at hospital arrival for patients in cardiovascular shock. Clinical Trial Registration: http://www.umin.ac.jp/ctr/, Unique identifier: 000008441.

Impact of Enteral Nutrition Within 24 Hours Versus Between 24 and 48 Hours in Patients With Severe Acute Pancreatitis: A Multicenter Retrospective Study.

OBJECTIVES: In patients with severe acute pancreatitis (SAP), early enteral nutrition (EN) is recommended by major clinical practice guidelines, but the exact timing for the initiation of EN is unknown. METHODS: We conducted a post hoc analysis of the database for a multicenter (44 institutions) retrospective study of patients with SAP in Japan. The patients were classified into 3 groups according to the timing of EN initiation after the diagnosis of SAP: within 24 hours, between 24 and 48 hours, and more than 48 hours. The primary outcome was in-hospital mortality. RESULTS: Of the 1094 study patients, 176, 120, and 798 patients started EN within 24 hours, between 24 and 48 hours, and more than 48 hours after SAP diagnosis, respectively. On multivariable analysis, hospital mortality was significantly better with EN within 48 hours than with more than 48 hours (adjusted odds ratio, 0.49; 95% confidence interval, 0.29-0.83; P < 0.001) but did not significantly differ between the groups with EN starting within 24 hours and between 24 and 48 hours (P = 0.29). CONCLUSIONS: Enteral nutrition within 24 hours may not confer any additional benefit on clinical outcomes compared with EN between 24 and 48 hours.

Early induction of hypothermia during cardiac arrest improves neurological outcomes in patients with out-of-hospital cardiac arrest who undergo emergency cardiopulmonary bypass and percutaneous coronary intervention.

BACKGROUND: Therapeutic hypothermia for comatose survivors of out-of-hospital cardiac arrest has demonstrated neurological benefits. Although early cooling during cardiac arrest enhances efficacy in animal studies, few clinical studies are available. METHODS AND RESULTS: The 171 patients who failed to respond to conventional cardiopulmonary resuscitation were studied prospectively. Patients underwent emergency cardiopulmonary bypass (CPB) plus intra-aortic balloon pumping, with subsequent percutaneous coronary intervention (PCI) if needed. Mild hypothermia (34 degrees C for 3 days) was induced during cardiac arrest or after return of spontaneous circulation. Of the 171 patients, 21 (12.3%) had a favorable neurological outcome at hospital discharge. An unadjusted rate of favorable outcome decreased in a stepwise fashion for increasing quartiles of collapse-to-34 degrees C interval (P=0.016). An adjusted odds ratio for favorable outcome after collapse-to-CPB interval was 0.89 (95% confidence interval (CI) 0.82-0.97) and after CPB-to-34 degrees C interval, 0.99 (95%CI 0.98-0.99) when collapse-to-34 degrees C interval was divided into 2 components. Favorable neurological accuracy of a collapse-to-CPB interval at a cutoff of 55.5 min and CPB-to-34 degrees C interval at a cutoff of 21.5 min was 85.4% and 89.5%, respectively. CONCLUSIONS: Early attainment of a core temperature had neurological benefits for patients with out-of-hospital cardiac arrest who underwent CPB and PCI. (Circ J 2010; 74: 77 - 85).

The Effect of an Invasive Strategy for Treating Pancreatic Necrosis on Mortality: a Retrospective Multicenter Cohort Study.

BACKGROUND: Infected acute necrotic collections (ANC) and walled-off necrosis (WON) of the pancreas are associated with high mortality. The difference in mortality between open necrosectomy and minimally invasive therapies in these patients remains unclear. METHODS: This retrospective multicenter cohort study was conducted among 44 institutions in Japan from 2009 to 2013. Patients who had undergone invasive treatment for suspected infected ANC/WON were enrolled and classified into open necrosectomy and minimally invasive treatment (laparoscopic, percutaneous, and endoscopic) groups. The association of each treatment with mortality was evaluated and compared. RESULTS: Of 1159 patients with severe acute pancreatitis, 122 with suspected infected ANC or WON underwent the following treatments: open necrosectomy (33) and minimally invasive treatment (89), (laparoscopic three, percutaneous 49, endoscopic 37). Although the open necrosectomy group had a significantly higher mortality on univariate analysis (p = 0.047), multivariate analysis showed no significant associations between open necrosectomy or Charlson index and mortality (p = 0.29, p = 0.19, respectively). However, age (for each additional 10 years, p = 0.012, odds ratio [OR] 1.50, 95% confidence interval [CI] 1.09-2.06) and revised Atlanta criteria-severe (p = 0.001, OR 7.84, 95% CI 2.40-25.6) were significantly associated with mortality. CONCLUSIONS: In patients with acute pancreatitis and infected ANC/WON, age and revised Atlanta criteria-severe classification are significantly associated with mortality whereas open necrosectomy is not. The mortality risk for patients undergoing open necrosectomy and minimally invasive treatment does not differ significantly. Although minimally invasive surgery is generally preferred for patients with infected ANC/WON, open necrosectomy may be considered if clinically indicated.