Prognostic study of sentinel lymph node biopsy in early-stage oral squamous cell carcinoma with computed tomography lymphography.

PURPOSE: Occult metastasis is a prognostic factor for early-stage oral squamous cell carcinoma (OSCC). Sentinel lymph node (SLN) biopsy (SLNB) is a promising method to detect such metastases. The present study aimed to evaluate the diagnostic reliability of SLNB with computed tomography lymphography (CTL) for early-stage OSCC and to clarify patient outcomes after SLNB. METHODS: The medical records of 42 patients with T1 or T2 cN0 OSCC who had undergone CTL the day before surgery were retrospectively collected and statistically analyzed. RESULTS: SLNs were identified on CTL in 41 of 42 OSCC patients (97.6 %). Micrometastases were detected in 10 of 41 cases (24.4 %) and 11 of 65 SLNs (16.9 %) by intraoperative pathological diagnosis. Three cases showed occult metastasis within a year after the primary operation. Specificity and negative predictive value were 76.9 % and 90.3 %, respectively. The cumulative 5-year regional recurrence-free rate was 89.7 % in 31 SLNB-negative patients. Five-year overall and disease-free survival rates were 86.9 % and 70.1 %, respectively, in the 41 cases with identified SLNs. CONCLUSION: CTL offers acceptable results and appears likely to be effective in treating early-stage OSCC patients with low-invasive surgery. Further investigation is necessary to compare radioisotope-based methods.

Combined computed tomography and C-arm resuscitation room system (CTCARM) is associated with decreased time to definitive hemostasis and reduces preperitoneal pelvic packing maneuvers in severe pelvic trauma.

Objectives: Severe pelvic fracture concomitant with massive bleeding is potentially lethal, and intervention for hemorrhage control still depends on institutional supplies. With the recent installation of a CT and C-arm combined resuscitation room system (CTCARM) for treatment of trauma patients in our institution, the strategic process and options for hemorrhage control after pelvic fracture have changed. We retrospectively reviewed the procedures we performed and their outcomes. Methods: The CTCARM was installed in our trauma resuscitation room in April 2020. Patients who were diagnosed as having pelvic fracture and underwent interventional radiology for hemorrhage control within 2.5 hours after arrival were compared before and after CTCARM installation. We reviewed the time process for hemorrhage control, treatment options performed, blood products used and their outcomes. Results: Included in this study were 56 patients treated between 2016 and 2022, of whom 36 patients were treated before (original group) and 20 patients after CTCARM installation (CTCARM group). Patient characteristics and vital signs at admission were not statistically different. Preperitoneal pelvic packing was performed significantly more frequently in the original group (p<0.01), whereas resuscitative endovascular balloon occlusion of the aorta use was much more frequent in the CTCARM group (p=0.02). Although the times from admission to first angiography (p=0.014) and to complete hemostasis (p=0.02) were significantly shorter in the CTCARM group, mortality was not statistically different. Four preventable trauma deaths occurred in the original group, but there were none in the CTCARM group. Six unexpected survivors were observed in the original group and four in the CTCARM group. Conclusions: Although the CTCARM had no direct effects on patient mortality for now, it has allowed us to accelerate the treatment time process, shorten preperitoneal pelvic packing procedural time, and potentially avoid subsequent preventable trauma deaths. Level of evidence: Level IV.

Warning about potential incidents of critical hyperkalemia during massive transfusion protocol after the preservation period of red blood cell products was extended in Japan.

Background: Recently, the Japanese Red Cross Society approved extension of the preservation period of red blood cell products. Since then, we have already experienced two cases of critical hyperkalemia during massive transfusion protocol (MTP). Case Presentation: Case 1, a 24-year-old man was stabbed in his right posterior chest. Although quick hemorrhage control was completed 35 min after arrival, his potassium level increased from 3.5 to 8.9 mEq/L within 40 min. Case 2, a 44-year-old man was transferred to our hospital after a car hit him. We immediately started resuscitation including MTP and opened his abdomen 24 min after arrival. His potassium level increased from 3.5 to 7.8 mEq/L within 38 min. Conclusion: Although several other factors might be causing this rise in potassium, we consider the extended preservation periods of red blood cell products to be one cause of these unexpectedly rapid rises in potassium during MTP.

Factors associated with the outcome of patients with COVID-19 requiring mechanical ventilation: A single-center observational study in Japan.

Aim: Coronavirus disease (COVID-19) spread worldwide, and was declared as a pandemic by the World Health Organization. Despite numerous studies in the last few years, the factors associated with the outcomes of patients with COVID-19 requiring mechanical ventilation remain unclear. The prediction of ventilator weaning and mortality using the data obtained at the time of intubation could be beneficial for establishing appropriate treatment strategies and obtaining informed consent. In this study, we aimed to clarify the association between patient information at the time of intubation and the outcomes of intubated COVID-19 patients. Methods: This retrospective observational study used single-center data from patients with COVID-19. Patients with COVID-19 who were admitted to Osaka Metropolitan University Hospital from April 1, 2020, to March 31, 2022, and under mechanical ventilation were included. The main outcome was defined as the factors related to ventilator weaning; a multivariate analysis was carried out to evaluate the association between patient information at the time of intubation and the outcome. Results: In total, 146 patients were included in this study. The factors significantly associated with ventilator weaning were age (65-74 years old, adjusted odds ratio [OR], 0.168; 75 years and older, adjusted OR, 0.121), vaccination history (adjusted OR, 5.655), and Sequential Organ Failure Assessment (SOFA) respiration score (adjusted OR, 0.007) at the time of intubation. Conclusion: Age, SOFA respiration score, and COVID-19 vaccination history at the time of intubation could be associated with outcomes in patients with COVID-19 requiring mechanical ventilation.

Demand-supply balance of disaster medical care in Osaka City based on damage estimation for a Nankai Trough megathrust earthquake: A geographic information system-based analysis.

Aim: Studies have not fully examined whether the medical care system would be able to manage the high number of casualties due to a Nankai Trough earthquake, whose probability of recurrence in the next 30 years is ~70%. This study assessed the demand-supply balance of the disaster medical care system in Osaka city by integrating the data on damage estimation and disaster coping hospitals using a geographic information system. Methods: We obtained data on the distribution of casualties in two cases, high and low rates of evacuation from the tsunami, and available beds in Osaka city calculated from operating data of each disaster coping hospital. We expanded these data on a geographic information system and investigated the balance of medical care. Results: The total number of available beds in the disaster medical care facilities was 5,559, and the shortage with evacuation rates being either low or high, would be 47,631 and 1,487, respectively. With a low evacuation rate, bed shortage is a common occurrence in coastal areas. With a high evacuation rate, bed shortage decreases, and problems with medical care arise in the eastern area of Osaka city. Discussion: In the case of a low evacuation rate, greater bed shortage was found along the coast of Osaka Bay where the probabilities of flooding are high. In the case of a high evacuation rate, however, the number of casualties was much lower. A shortage of medical care did not occur along the coast, but in the eastern part of Osaka city.

Protocol for a multicentre, prospective observational study of elective neck dissection for clinically node-negative oral tongue squamous cell carcinoma (END-TC study).

INTRODUCTION: In early-stage oral tongue squamous cell carcinoma (OTSCC), elective neck dissection (END) is recommended when occult lymph node metastasis is suspected; however, there is no unanimous consensus on the risks and benefits of END in such cases. The management of clinically node-negative (cN0) OTSCC remains controversial. This study, therefore, aimed to evaluate the efficacy of END and its impact on the quality of life (QoL) of patients with cN0 OTSCC. METHODS AND ANALYSIS: This is a prospective, multicentre, nonrandomised observational study. The choice of whether to perform END at the same time as resection of the primary tumour is based on institutional policy and patient preference. The primary endpoint of this study is 3-year overall survival. The secondary endpoints are 3-year disease-specific survival, 3-year relapse-free survival and the impact on patient QoL. Propensity score-matching analysis will be performed to reduce selection bias. ETHICS AND DISSEMINATION: This study was approved by the Clinical Research Review Board of the Nagasaki University. The protocol of this study was registered at the University Hospital Medical Information Network Clinical Trials Registry. The datasets generated during the current study will be available from the corresponding author on reasonable request. The results will be disseminated internationally, through scientific and professional conferences and in peer-reviewed medical journals. TRIAL REGISTRATION NUMBER: UMIN000027875.

Clinical evaluation of cell-direct polymerase chain reaction-based nucleic acid lateral flow immunoassay for rapid detection of bacterial pathogens in clinically suspected sepsis: A multi-center study in Japan.

Blood culture, a method for identifying causative agents of bacterial sepsis, requires several days. The combination of cell-direct polymerase chain reaction and nucleic acid lateral flow immunoassay (cdPCR-NALFIA) is a simple and sensitive detection method for identifying pathogenic bacteria. Furthermore, this assay, when applied directly to blood samples yields results within 4.5 h, without requiring culture. This study was performed at five hospitals in Japan between 2013 and 2016. Blood samples from 73 patients with clinically suspected sepsis yielded 18 positive blood cultures, and the isolated bacterial species were detectable using cdPCR-NALFIA in nine samples. Thirteen samples were positive on cdPCR-NALFIA. In total, 17 samples confirmed to have bacterial species were detectable using cdPCR-NALFIA and/or blood culture with a true positive rate of 76.5% and 64.7%, respectively. The combination of blood culture and cdPCR-NALFIA could improve the rate of detection of bacterial sepsis.

Discrepant Antigen-specific Antibody Responses Causing SARS-CoV-2 Persistence in a Patient Receiving B-cell-targeted Therapy with Rituximab.

A 73-year-old man previously treated with rituximab for his mucosa-associated lymphoid tissue lymphoma suffered a suboptimal humoral immune response against an acquired SARS-CoV-2 infection. A detailed serological description revealed discrepant antigen-specific humoral immune responses. The titer of spike-targeting, "viral-neutralizing" antibodies remained below the detection level, in contrast to the anti-nucleocapsid, "binding" antibody response, which was comparable in both magnitude and kinetics. Accordingly, viral neutralizability and clearance was delayed, leading to prolonged RNAemia and persistent pneumonia. The present case highlights the need to closely monitor this unique population of recipients of B-cell-targeted therapies for their neutralizing antibody responses against SARS-CoV-2.

Successful limb salvage beyond the golden time following blunt traumatic open complete transection of the femoral artery and vein in a patient with cardiac arrest: a case report.

BACKGROUND: Open complete transection of the femoral artery and vein following blunt trauma is extremely rare. Furthermore, even if the patient has been successfully resuscitated, it is sometimes difficult in most patients to preserve the injured limb, especially after damage control resuscitation. We report a case of open complete transection of the femoral artery and vein secondary to high-energy blunt trauma and a successful limb preservation treatment strategy. CASE PRESENTATION: A 57-year-old Asian man was transferred to hospital after having fallen from the 15th floor of a condominium. The patient was in cardiac arrest at the scene, but was successfully resuscitated by emergency medical services staff. On arrival, the patient's hemodynamics were completely collapsed with active external bleeding from the thigh, so we immediately started resuscitation including activation of massive transfusion protocol and temporarily ligated the transected proximal superficial femoral artery, deep femoral artery just distal after branching lateral femoral circumflex artery and the superficial femoral vein. Following radiological findings showing a potential pelvic fracture with active bleeding, we also performed retroperitoneal packing in the resuscitation room and moved the patient to the angiography room for transcatheter arterial embolization. The patient's consciousness was preserved and perfusion of the injured limb was barely maintained after his hemodynamics were adequately stabilized. As we detected weak perfusion of the lower limb via a potential collateral flow from the lateral femoral circumflex artery branches from deep femoral artery by pulse doppler of the dorsal pedis artery, we decided to reconstruct superficial femoral artery and vein at 24 h after injury using great saphenous vein bypass grafts. The patient was transferred to a rehabilitation hospital with good neurological and limb outcome after hospitalization for 52 days. CONCLUSION: We successfully preserved the patient's lower limb after cardiac arrest and complete transection of the femoral artery and vein and achieved a good neurological outcome. Even if a femoral artery needs to be ligated temporarily, careful observation and assessment should be performed so as not to lose the chance to salvage the limb even during damage control resuscitation.

Successful surgical treatment approach for mitral valve vegetation of infective endocarditis after severe soft tissue infection with mediastinitis.

Transesophageal echocardiography is mandatory if you do suspect infective endocarditis. By approaching via a small right thoracotomy, vegetectomy and mitral valvuloplasty following severe mediastinitis were successfully accomplished without any complications.

COVID-19-associated pulmonary aspergillosis in a Japanese man: A case report.

CAPA (COVID-19 associated pulmonary aspergillosis) is an important complication of COVID-19. It has been reported that the incidence of CAPA is as high as 19%-33% worldwide. However, its onset has not been reported in Japan. A 72-year-old Japanese man was diagnosed with COVID-19 and was transferred to our hospital due to deterioration of respiratory condition. Treatment with remdesivir, dexamethasone (DEXA), and antibiotics was performed under mechanical ventilation. Although the condition improved temporarily, a new shadow appeared in the lung, and Aspergillus fumigatus was cultured from sputum. The patient was clinically diagnosed with CAPA and treated with voriconazole. However, his progress deteriorated and he died. High-risk COVID-19 patients should be tested for Aspergillus to ensure early diagnosis of CAPA.

Long-term outcomes of surgical rib fixation in patients with flail chest and multiple rib fractures.

BACKGROUND: Recently, interest has increased in surgical fixation for severe thoracic wall injury with good short-term outcomes. However, few reports have evaluated long-term outcomes or complications. This study aimed to assess long-term quality of life and implant-related complications after rib fixation for flail chest and multiple rib fractures. METHODS: We interviewed patients who had undergone rib fixation from January 2014 to December 2019 about their current ability to work and their usual life. RESULTS: Twenty-two patients underwent rib fixation during the study period. Two patients with flail chest had already died after the surgery due to senescence; thus, follow-up information was obtained from 20 patients (91%), with a follow-up duration of 47.5 (IQR 22-58) months. The most undesirable event occurring during the study period was irritation caused by a palpable plate (n=2, 10%), probably due to the thin skin of patients over 70 years old. Eighteen patients were able to return to their usual life or same work as in the premorbid state with no complaints. Two patients are still undergoing rehabilitation due to concomitant extremities fractures. The median EQ-5D-5L index score was 0.89 (IQR 0.84-0.93). There were no implant-related complications requiring plate explantation. DISCUSSION: We concluded that rib fixation offers good long-term benefits, with the ability of the patient with flail chest or multiple rib fractures to return to activity in the premorbid state. Elderly patients especially with thin, soft tissue may complain of irritation caused by the plate and should be informed of this prior to surgery. LEVEL OF EVIDENCE: Level IV therapeutic care/management.

How to deploy a uniform and simplified acute-phase management strategy for traumatic pancreatic injury in any situation.

AIM: Management of traumatic pancreatic injury is challenging, and mortality and morbidity remain high. Because pancreatic injury is uncommon and strong recommendations for pancreatic injury management are lacking, management is primarily based on institutional practices. We propose our strategy of pancreatic injury management. METHODS: We retrospectively reviewed patients with pancreatic injury and evaluated our strategy and outcomes. RESULTS: From January 2013 to December 2019, 18 patients were included with traumatic pancreatic injury. The median Injury Severity Score was 22 (25-75% interquartile range, 17-34) and probability of survival was 0.87 (25-75% interquartile range, 0.78-0.93). Patients were grouped according to the American Association for the Surgery of Trauma injury grades: grade I, n = 3 (16.7%); II, n = 6 (33.3%); III, n = 7 (38.9%); and IV, n = 2 (11.1%). All patients underwent endoscopic pancreatic ductal evaluation within 1-2 days after admission. Abbreviated surgery because of hemodynamic instability and subsequent open abdominal management were undertaken in one patient with pancreas head injury and two patients with pancreas body/tail injury. Management was by laparotomy for closed suction drain insertion with main ductal endoscopic drainage in six patients, endoscopic ductal drainage only in six patients, and distal pancreatectomy with closed suction drainage and endoscopic drainage in five patients. One patient with grade I injury underwent observation only. Median length of closed suction drainage was 12 days and that of hospital stay was 36 days. The observed mortality during the study period was 0%. Late formation of pseudo-pancreatic cyst was observed in two patients (11.1%). CONCLUSION: Our uniform, simplified strategy offers good outcomes for any pancreatic injury site and any concomitant injuries, even in hemodynamically unstable patients.

The impact of early administration of vasopressor agents for the resuscitation of severe hemorrhagic shock following blunt trauma.

BACKGROUND: When resuscitating patients with hemorrhagic shock following trauma, fluid volume restriction and permissive hypotension prior to bleeding control are emphasized along with the good outcome especially for penetrating trauma patients. However, evidence that these concepts apply well to the management of blunt trauma is lacking, and their use in blunt trauma remains controversial. This study aimed to assess the impact of vasopressor use in patients with blunt trauma in severe hemorrhagic shock. METHODS: In this single-center retrospective study, we reviewed records of blunt trauma patients with hemorrhagic shock and included patients with a probability of survival < 0.6. Vital signs on arrival, characteristics, examinations, concomitant injuries and severity, vasopressor use and dose, and volumes of crystalloids and blood infused were compared between survivors and non-survivors. Data are described as median (25-75% interquartile range) or number. RESULTS: Forty patients admitted from April 2014 to September 2019 were included. Median Injury Severity Score in survivors vs non-survivors was 41 (36-48) vs 45 (34-51) (p = 0.48), with no significant difference in probability of survival between the two groups (0.22 [0.12-0.48] vs 0.21 [0.08-0.46]; p = 0.93). Despite no significant difference in patient characteristics and injury severity, non-survivors were administered vasopressors significantly earlier after admission and at significantly higher doses. Total blood transfusion amount administered within 24 h after admission was significantly higher in survivors (8430 [5680-9320] vs 6540 [4550-7880] mL; p = 0.03). Max catecholamine index was significantly higher in non-survivors (2 [0-4] vs 14 [10-18]; p = 0.008), and administered vasopressors were terminated significantly earlier (12 [4-26] vs 34 [10-74] hours; p = 0.026) in survivors. Although the variables of severity of the patients had no significant differences, vasopressor use (Odds ratio [OR] = 21.32, 95% confident interval [CI]: 3.71-121.6; p = 0.0001) and its early administration (OR = 10.56, 95%CI: 1.90-58.5; p = 0.005) indicated significant higher risk of death in this study. CONCLUSION: Vasopressor administration and high-dose use for resuscitation of hemorrhagic shock following severe blunt trauma are potentially associated with increased mortality. Although the transfused volume of blood products tends to be increased when resuscitating these patients, early termination of vasopressor had better to be considered.

How emergency physicians choose chest tube size for traumatic pneumothorax or hemothorax: a comparison between 28Fr and smaller tube.

Most traumatic pneumothoraxes and hemothoraxes can be managed non-operatively by means of chest tube thoracostomy. This study aimed to investigate how emergency physicians choose chest tube size and whether chest tube size affects patient outcome. We reviewed medical charts of patients who underwent chest tube insertion for chest trauma within 24 hours of admission in this retrospective, single-institution study. Patient characteristics, inserted tube size, risk of additional tube, and complications were evaluated. Eighty-six chest tubes were placed in 64 patients. Sixty-seven tubes were placed initially, and 19 additionally, which was significantly smaller than the initial tube. Initial tube size was 28 Fr in 38 and <28 Fr in 28 patients. Indications were pneumothorax (n=24), hemothorax (n=7), and hemopneumothorax (n=36). Initial tube size was not related to sex, BMI, BSA, indication, ISS, RTS, chest AIS, or respiratory status. An additional tube was placed in the same thoracic cavity for residual pneumothorax (n=13), hemothorax (n=1), hemopneumothorax (n=1), and inappropriate extrapleural placement (n=3). Risk of additional tube placement was not significantly different depending on tube size. No additional tube was placed for tube occlusion or surgical intervention for residual clotted hemothorax. Emergency physicians did not choose tube size depending on patient sex, body size, or situation. Even with a <28 Fr tube placed in chest trauma patients, the risk of residual hemo/pneumothorax and tube occlusion did not increase, and drainage was effective.

Efficacy and safety of TEVAR with debranching technique for blunt traumatic aortic injury in patients with severe multiple trauma.

BACKGROUND: Blunt traumatic aortic injury (BTAI) patients are severely ill, with high mortality and morbidity. As 60% of BTAIs occur in the distal arch, left subclavian artery (LSCA) management is determined without knowing posterior cerebral or left arm circulation in emergent cases. Because we perform thoracic endovascular aortic repair (TEVAR) + debranching technique for thoracic BTAI, we assessed efficacy and safety of debranching TEVAR in BTAI patients. METHODS: We retrospectively reviewed vital signs on arrival, injury mechanism, characteristics, clinical time-series, concomitant injuries, injury description, operative procedures, and results from patient records. We excluded patients in cardiopulmonary arrest on arrival. RESULTS: From April 2014 to December 2018, nine of 25 patients admitted with BTAI underwent TEVAR. Median Injury Severity Score was 34 (29-34) and probability of survival was 0.82 (0.16-0.94). Society for Vascular Surgery BTAI injury grade was III or IV in all patients. Three patients underwent simple TEVAR and six underwent debranching TEVAR (LSCA occlusion + left common carotid artery to LSCA bypass). Median operation time was 108 (75-157) min for simple TEVAR and 177 (112-218) min for debranching TEVAR. Concomitant injuries included intracranial hemorrhage (N = 1), intra-abdominal injuries (N = 3), pneumo- or hemothoraxes (N = 4) and pelvic/extremities fractures (N = 7). Only one complication of left-hand claudication occurred postoperatively in a patient with simple TEVAR with LSCA occlusion. CONCLUSION: Despite debranching TEVAR taking approximately 60 min longer than simple TEVAR, short-term results indicated it to be acceptable for BTAI in multiple trauma patients to avoid LSCA complications unless we fail to stop bleeding first.

The Elental® elemental diet for chemoradiotherapy-induced oral mucositis: A prospective study in patients with oral squamous cell carcinoma.

Oral mucositis is a common adverse effect of cancer treatment that can increase the risk for local and systemic infection. This prospective study was designed to evaluate the preventive effects of an amino-acid-rich elemental diet (ED), Elental®, on radiotherapy- or chemoradiotherapy-induced mucositis in oral squamous cell carcinoma (OSCC) patients. Fifty patients were enrolled in this prospective study, who had received radiation (60-70 Gy) with/without chemotherapy [S-1, UFT, cisplatin (CDDP), docetaxel (DOC) plus CDDP, or Cetuximab]. The Elental® group (25 patients) had received Elental® during treatment, and the control group (25 patients) had not. Multivariate logistic regression analysis was used to identify the factors related to abatement of oral mucositis. A comparison of the rates of completion of chemoradiation treatments as well as the nutritional or inflammatory status between Elental® and control groups was performed. Multivariate analysis indicated that most of the patients who received Elental® suffered from a lower degree of mucositis and showed significantly improved rate of completion of chemoradiation (no interruption) compared to the control group. There was a significant difference between the Elental® group and the control group in terms of the mean change of C-reactive protein (CRP) levels in blood serum; however, there was no significant difference in terms of a mean change of body weight and total protein level in blood serum before and after chemoradiation. Our study shows that the Elental® elemental diet could be useful for the treatment of oral mucositis induced by chemoradiation. Elental® might also promote improved completion rates of chemoradiotherapy in OSCC patients.