Novel Peritoneal Sclerosis Rat Model Developed by Administration of Bleomycin and Lansoprazole.

In our preliminary experiment, peritoneal sclerosis likely induced by peritoneal dialysis was unexpectedly observed in the livers of rats given bleomycin and lansoprazole. We examined whether this peritoneal thickening around the liver was time-dependently induced by administration of both drugs. Male Wistar rats were injected with bleomycin and/or lansoprazole for 2 or 4 weeks. The 3YB-1 cell line derived from rat fibroblasts was treated by bleomycin and/or lansoprazole for 24 h. The administration of both drugs together, but not individually, thickened the peritoneal tissue around the liver. There was accumulation of collagen fibers, macrophages, and eosinophils under mesothelial cells. Expressions of Col1a1, Mcp1 and Mcp3 genes were increased in the peritoneal tissue around the liver and in 3YB-1 cells by the administration of both drugs together, and Opn genes had increased expressions in this tissue and 3YB-1 cells. Mesothelial cells indicated immunoreactivity against both cytokeratin, a mesothelial cell marker, and αSMA, a fibroblast marker, around the livers of rats given both drugs. Administration of both drugs induced the migration of macrophages and eosinophils and induced fibrosis associated with the possible activation of fibroblasts and the possible promotion of the mesothelial-mesenchymal transition. This might become a novel model of peritoneal sclerosis for peritoneal dialysis.

Intraoperative techniques to prevent deep incisional or organ-space surgical site infection after emergency surgery for nonappendiceal perforation peritonitis: a prospective two-center observational study.

PURPOSE: The rate of surgical site infection (SSI) after surgery for secondary peritonitis is very high. This study investigated the relationship between intraoperative procedures of emergency surgery for nonappendiceal perforation peritonitis and deep incisional or organ-space SSI. METHODS: This prospective, two-center observational study included patients aged ≥ 20 years who underwent emergency surgery for perforation peritonitis between April 2017 and March 2020. We compared patients with deep incisional or organ-space SSI (Group S) to patients without SSIs or with superficial incisional SSIs (Group C). Thereafter, we evaluated the association between intraoperative technical variables and deep incisional or organ-space SSI using a multivariate logistic regression model. All multivariate analyses were adjusted for potentially relevant risk factors (e.g., age, body mass index, diabetes, smoking habit, and National Nosocomial Infection Surveillance risk index). RESULTS: Of the 75 participants, 14 were in Group S and 61 were in Group C. The use of a wound protector device was significantly associated with decreased odds of deep incisional or organ-space SSI (adjusted odds ratios [AOR], 0.017; 95% confidence intervals [CI] 0.0014-0.19, p = 0.0011). A 1000 ml increase in intra-abdominal lavage with normal saline was significantly associated with increased odds of deep incisional or organ-space SSI (AOR: 1.28, 95% CI 1.02-1.61, p = 0.033). CONCLUSION: Wound protector devices should be used in emergency surgery for nonappendiceal perforation peritonitis. Excessive intra-abdominal lavage with normal saline for peritonitis may have unsatisfactory benefits and increases the incidence of deep incisional or organ-space SSI.

Is damage control surgery useful in the treatment of colorectal perforation? A single-center case-control study.

Colorectal perforation with systemic peritonitis requires prompt surgical attention, and damage control surgery (DCS) is performed in patients with severe injuries. This study aimed to retrospectively investigate the efficacy of DCS in patients with colonic perforation. Materials and Methods: From January 2013 to December 2019, 131 patients with colorectal perforation underwent emergency surgery at our hospital. Among these, 95 patients required postoperative intensive care unit management and were included in this study; of these patients, 29 (31%) underwent DCS, and 66 (69%) underwent primary abdominal closure (PC). Results: Patients who underwent DCS had significantly higher Acute Physiology and Chronic Health Evaluation II (23.9 [19.5-29.5] vs. 17.6 [13.7-22]; P<0.0001) and Sequential Organ Failure Assessment (SOFA) (9 [7-11] vs. 6 [3-8]; P<0.0001) scores than did those who underwent PC. The initial operation time was significantly shorter for DCS than for PC (99 [68-112] vs. 146 [118-171]; P<0.0001). The 30-day mortality and colostomy rates were not significantly different between the two groups. Conclusions: The results suggest that DCS is useful in the management of acute generalized peritonitis caused by colorectal perforation.

Activities of daily living and psychiatric symptoms after intensive care unit discharge among critically ill patients with or without tracheostomy: a single center longitudinal study.

Aim: Tracheostomy is widely performed in critically ill patients who require prolonged mechanical ventilation. Long-term morbidity (post-intensive care syndrome) in tracheostomized patients is not widely reported, however, so we evaluate it here. Methods: This is a sub-analysis of a single center prospective longitudinal study, which assessed activities of daily living (ADL) and psychiatric symptoms in adult patients emergently admitted to the intensive care unit (ICU). We evaluated association between these symptoms and tracheostomy by posting questionnaires at 3 and 12 months after ICU discharge. Results: We analyzed 107 patients (15 patients with tracheostomy) at 3 months and 74 patients (13 patients with tracheostomy) at 12 months after ICU discharge. ADL tended to be lower in patients with tracheostomy than in those without tracheostomy at 3 months after ICU discharge (65 [10-100] versus 95 [59-100]; P = 0.28, 7/15 [47%] versus 30/102 [30%] Barthel Index scored ≤ 60; P = 0.23), however there were no significant differences. Psychiatric symptoms were not different between the groups at 3 months and again at 12 months. Conclusion: Activities of daily living disability and psychiatric symptoms were not significantly worse in patients with tracheostomy at 3 and 12 months from ICU discharge compared with patients without tracheostomy. Despite the limited number in our cohort, our study may inform shared decision making concerning tracheostomy for critically ill patients and their families.

Life-threatening gastrointestinal bleeding from splenic artery pseudoaneurysm due to gastric ulcer penetration treated by surgical hemostasis with resuscitative endovascular balloon occlusion of the aorta: A case report.

We report the case of a patient for whom surgical hemostasis of gastrointestinal bleeding due to a splenic artery pseudoaneurysm, which developed due to gastric ulcer penetration, was achieved with resuscitative endovascular balloon occlusion of the aorta without ischemia of organs including the spleen.

Do synbiotics really enhance beneficial synbiotics effect on defecation symptoms in healthy adults?: Randomized, double-blind, placebo-controlled trial.

GOALS: We examined whether synbiotics enhance improvement by probiotics. BACKGROUND: Probiotics, which are beneficial microbacteria, are a nutritional intervention for treatment of functional constipation or its tendency. Prebiotics, meanwhile, can promote the proliferation of probiotics in the gastrointestinal tract and enhance their beneficial effects. Synbiotics, a combination of probiotics and prebiotics, may be superior to probiotics in the treatment of defecation-related symptoms, but this requires elucidation. STUDY: This randomized, double-blind, placebo-controlled study enrolled 69 healthy adults with constipation tendency. Participants were allocated to either control, probiotics, or synbiotics groups and they recorded details of their defecations and their condition. The first 2 weeks were the observation period and the latter 2 weeks were the intervention period, in which participants took test foods. Probiotic foods included Bifidobacterium longum NT strain (1010 CFU/day), synbiotic foods included the NT strain (1010 CFU/day) and galactooligosaccharide (1 g/day). Placebo foods contained the vehicle only. Participants answered questionnaires (Patient Assessment on Constipation Symptoms [PAC-SYM], and one on dietary history) on the last day of each period. RESULTS: Nine participants withdrew consent, and 2 of the remaining 60 had missing data. Age, body mass index, and sex were not significantly different between the 3 groups. Frequency of bowel movements in the fourth week, the primary endpoint, was not increased in the probiotics or synbiotics groups compared with the control group, and the frequency of bowel movements and days with defecation were not changed by probiotics or synbiotics during the intervention period. Probiotics and synbiotics did not improve stool conditions, although incomplete defecation was improved by probiotics but not by synbiotics compared with placebo. PAC-SYM indicated that stool condition and total scores were improved by probiotics but not by synbiotics during the intervention compared with placebo. CONCLUSION: The probiotic strain Bifidobacterium longum NT can improve constipation symptoms, especially stool condition, but it does not increase bowel movement frequency in healthy adults with constipation tendency. Synbiotics treatment seemed to diminish this improvement of constipation induced by probiotics. This study indicates the possibility of attenuation of beneficial effects from probiotics by the use of synbiotics, contrary to synbiotics theory.

Prediction of early acute kidney injury after trauma using prehospital systolic blood pressure and lactate levels: A prospective validation study.

BACKGROUND: Acute kidney injury (AKI) after trauma is a major complication independently associated with a prolonged hospital stay and increased mortality. We previously reported that the prehospital systolic blood pressure (SBP) and early hospital arterial lactate level, along with specific cut-off values, show good performance in the early prediction of AKI using AUC-ROC [1]. The purpose of this study was to prospectively validate whether or not these parameters are predictive of newly occurring AKI after trauma. METHODS: This was a prospective review of trauma patients who were admitted to a single trauma center from January to December 2019. Patients who were <16 years old, who had burns, and who had chronic kidney disease were excluded. AKI was defined according to the Risk, Injury, Failure, Loss of the kidney function, and End-stage kidney disease (RIFLE) classification based on serum creatinine alone. Patients with a low prehospital SBP (≤126 mmHg) and high lactate levels (≥2.5 mmol/L) were defined as the high-risk group, and other patients were defined as the low-risk group. RESULTS: A total of 489 trauma patients were admitted to our center, of whom 403 were eligible for the study. The high-risk group consisted of 38 patients, and the low-risk group consisted of 365 patients. The incidence of severe AKI in Stage Injury and Failure was significantly higher in the high-risk group (5 patients, 13.2%) than in the low-risk group (7 patients, 1.9%), with an odds ratio of 7.75 and 95% confidence interval of 2.33-25.77. CONCLUSIONS: These predictors showed good performance in the early prediction of severe AKI after trauma. Early prediction of the high-risk groups for severe AKI after trauma prompting early treatment may help improve the prognosis of trauma patients.

Prehospital Blood Pressure and Lactate are Early Predictors of Acute Kidney Injury After Trauma.

BACKGROUND: The purpose of this study is to report the prevalence of acute kidney injury (AKI) after trauma in our center, describe the risk factors associated with AKI, and determine whether these risk factors help avoid AKI. MATERIALS AND METHODS: We retrospectively analyzed the data which were prospectively collected from a single center trauma registry from January 2017 to December 2018. Patients who were <16 years of age, patients with burns, and patients with chronic kidney disease were excluded from the present study. AKI was defined according to the risk, injury, failure, loss of the kidney function, and end-stage kidney disease (RIFLE) classification from serum creatinine alone. A logistic regression analysis was performed to identify prehospital and early hospital risk factors for AKI. RESULTS: There were 806 trauma patients recorded in the database. One hundred thirty cases were excluded based on the abovementioned exclusion criteria. Six hundred seventy-six patients were included in the analysis. The prevalence of AKI in the overall population was 14.5% including 10.5% of patients with stage R, 3.0% of patients with stage I and 1.0% with stage F. The incidence of AKI increased to 36.3%, 12.1% and 3.3% in the subgroup of patients with hemorrhagic shock. The multivariate analysis revealed that the minimum prehospital systolic blood pressure and arterial lactate level were independent predictors of AKI. The model showed good discrimination with an area under the receiver operating characteristic curve (AUC-ROC) of 0.867 and 0.852 in the prediction of AKI stage I or F. The cutoff values were ≤126 mmHg and ≥2.5 mmol/L, respectively. CONCLUSION: These parameters showed good performance in the early prediction of AKI after trauma. They are associated with the early onset of AKI after trauma and may be an early predictor of the effects of treatment to prevent AKI.

Is open abdominal management useful in nontrauma emergency surgery for older adults? A single-center retrospective study.

PURPOSE: Open abdominal management (OAM) is being adopted increasingly frequently in nontrauma patients. This study assessed the effectiveness of OAM in nontrauma older adults. METHODS: We retrospectively reviewed all adults who underwent nontrauma emergency laparotomy requiring postoperative intensive care unit (ICU) management between September 2012 and August 2017 at our hospital. Patients ≥ 80 years old, who underwent OAM, were compared with those < 80 years old. The primary outcome was the 90-day mortality. Secondary outcomes were the 30-day mortality, unplanned relaparotomy, and the ICU length of stay (LOS). RESULTS: The OAM group comprised 58 patients, including 27 who were ≥ 80 years old. The patients ≥ 80 years old in the OAM group had a significantly higher 90-day mortality rate (33% vs. 10%; p = 0.027) than those < 80 years old. There were no significant differences in the 30-day mortality rate, patients' unplanned relaparotomy rate, or ICU LOS between the patients ≥ 80 years old and those < 80 in the OAM group. CONCLUSIONS: Older adults who underwent OAM had a significantly higher mortality rate than younger patients. However, the OAM strategy for older nontrauma patients may still be useful and reasonable considering the severe condition of these patients.

Surgical intervention for blunt bowel and mesenteric injury: indications and time intervals.

PURPOSE: Decision making in management of blunt bowel and mesenteric injury (BBMI) is difficult. This study aimed to identify indicators for laparotomy and appropriate time intervals to surgery. METHODS: We retrospectively reviewed our hospital's trauma registry to identify patients with a diagnosis of BBMI from February 2011 to July 2017. Patients requiring therapeutic surgical treatment (OM group) were compared with those who did not (NOM group). Preoperative risk factors for surgery (with p < 0.1 by univariate analysis) were integrated in a multivariate logistic regression model. In the OM group, we identified relevant factors for time intervals to surgical interventions. RESULTS: Among 2808 trauma patients admitted to our hospital, 83 (3.0%) had bowel and mesenteric injury; 6 patients with penetrating trauma, 2 lethal, untreated cases, and 2 patients who underwent exploratory laparotomy were excluded. Finally, 73 patients (47 males), with a mean Injury Severity Score (ISS) of 23, were included. Results from univariate analysis identified three relevant factors between the OM and NOM groups: ISS score (p = 0.036), hemodynamic instability (p = 0.041), and free air (p = 0.0018). Multivariate analysis revealed one relevant factor, free air (p = 0.0002). Short intervals between hospital admission and intervention were associated with 7-day mortality (p = 0.029), hemodynamic instability (p = 0.0009), focused assessment with sonography for trauma positive (p < 0.0001), and mesenteric extravasation (p = 0.012). CONCLUSIONS: Early surgical intervention is essential in cases of hemodynamically unstable BBMI and bowel perforation with free air; nevertheless, it is associated with high mortality. We suggest that prompt transport along with early intervention could significantly lessen mortality.

Outcomes of abdominal trauma patients with hemorrhagic shock requiring emergency laparotomy: efficacy of intra-aortic balloon occlusion.

Aim: The aims of this study were to investigate outcomes of abdominal trauma in patients with hemorrhagic shock requiring emergency laparotomy and clarify the beneficial effects of intra-aortic balloon occlusion (IABO) for intra-abdominal hemorrhage in patients with critically uncontrollable hemorrhagic shock (CUHS). Methods: We reviewed 44 hemorrhagic shock patients who underwent emergency laparotomy for intra-abdominal hemorrhage over a 6-year period. Of these patients, we examined data for 19 subjects who underwent IABO during initial resuscitation to control massive intra-abdominal bleeding leading to CUHS. Results: The average Injury Severity Score and probability of survival (Ps) of the 44 patients were 27.6 ± 15.4 and 0.735 ± 0.304, respectively, and the overall survival rate was 77.3%. The differences in the Glasgow Coma Scale, lactate level, prothrombin time - international normalized ratio, and Ps between the two groups (21 responders and 23 non-responders) were statistically significant (P < 0.05). Intra-aortic balloon occlusion was attempted in 19 of 23 patients (82.6%) with CUHS, and there were no statistically significant differences in presenting Glasgow Coma Scale, body temperature, lactate, prothrombin time - international normalized ratio, or Revised Trauma Score between the survivors (n = 12) and non-survivors (n = 7). The only significant differences between these two groups were observed in Injury Severity Score (P = 0.047) and Ps (P = 0.007). In all patients, the balloons were successfully placed in 8.1 ± 3.3 min in the thoracic aorta, and a significant increase in systolic blood pressure was observed immediately after IABO. Conclusion: The IABO procedure can be life-saving in the management of patients with CUHS arising from intra-abdominal hemorrhage, permitting transport to surgery.

[The "Susami information sharing system" facilitates cooperation between medical care, nursing care and senior care].

BACKGROUND: Susami is a typical rural town of which about 5,000 with a 40% aging rate, located in the south of Wakayama prefecture. The needs with regard to medical care, nursing care and senior care has been increasing every year. However, there are few staff members involved in such care services. To take better care of our community, we developed the "Susami information sharing system." METHODS: The subjects consisted of 2,600 people from Susami who provided their consent for their information to be shared. Using the information sharing system, the medical information, including prescriptions, infusions, imaging and laboratory data is automatically extracted from the electronic medical records at Susami hospital. Home nursing information is uploaded by a handheld unit by nurses at home nursing stations. Senior care information is also shared by care workers as part of the Susami social welfare association. Welfare information, including the results of basic medical examinations, cancer screening and vaccination data are uploaded by staff of the government office. Infrared motion sensors are installed in the homes of subjects living on their own to monitor their life activities. All information is collected by a shared host server through each information disclosure server. All information can be seen in the electronic medical records and PC monitors. RESULTS: The Susami government office administers this system under an annual budget, 3,800,000 yen. Most of the budget is the maintenance cost of the infrared motion sensors. The annual administration expense for the system's servers is 680,000 yen. CONCLUSIONS: Because the maintenance cost is relatively low, it is not difficult for small-scale governments like that in Susami to maintain this system. In the near future, we will consider allowing other departments and practitioners to connect to our system. This system has strengthened both mutual understanding and cooperation between patients, health care providers, nurses and caregivers.