Development and validation of a prehospital termination of resuscitation (TOR) rule for out - of hospital cardiac arrest (OHCA) cases using general purpose artificial intelligence (AI).

BACKGROUND: Prehospital identification of futile resuscitation efforts (defined as a predicted probability of survival lower than 1%) for out-of-hospital cardiac arrest (OHCA) may reduce unnecessary transport. Reliable prediction variables for OHCA 'termination of resuscitation' (TOR) rules are needed to guide treatment decisions. The Universal TOR rule uses only three variables (Absence of Prehospital ROSC, Event not witnessed by EMS and no shock delivered on the scene) has been externally validated and is used by many EMS systems. Deep learning, an artificial intelligence (AI) platform is an attractive model to guide the development of TOR rule for OHCA. The purpose of this study was to assess the feasibility of developing an AI-TOR rule for neurologically favorable outcomes using general purpose AI and compare its performance to the Universal TOR rule. METHODS: We identified OHCA cases of presumed cardiac etiology who were 18 years of age or older from 2016 to 2019 in the All-Japan Utstein Registry. We divided the dataset into 2 parts, the first half (2016-2017) was used as a training dataset for rule development and second half (2018-2019) for validation. The AI software (Prediction One®) created the model using the training dataset with internal cross-validation. It also evaluated the prediction accuracy and displayed the ranking of influencing variables. We performed validation using the second half cases and calculated the prediction model AUC. The top four of the 11 variables identified in the model were then selected as prognostic factors to be used in an AI-TOR rule, and sensitivity, specificity, positive predictive value, and negative predictive value were calculated from validation cohort. This was then compared to the performance of the Universal TOR rule using same dataset. RESULTS: There were 504,561 OHCA cases, 18 years of age or older, 302,799 cases were presumed cardiac origin. Of these, 149,425 cases were used for the training dataset and 153,374 cases for the validation dataset. The model developed by AI using 11 variables had an AUC of 0.969, and its AUC for the validation dataset was 0.965. The top four influencing variables for neurologically favorable outcome were Prehospital ROSC, witnessed by EMS, Age (68 years old and younger) and nonasystole. The AUC calculated using the 4 variables for the AI-TOR rule was 0.953, and its AUC for the validation dataset was 0.952 (95%CI 0.949 -0.954). Of 80,198 patients in the validation cohort that satisfied all four criteria for the AI-TOR rule, 58 (0.07%) had a neurologically favorable one-month survival. The specificity of AI-TOR rule was 0.990, and the PPV was 0.999 for predicting lack of neurologically favorable survival, both the specificity and PPV were higher than that achieved with the universal TOR (0.959, 0.998). CONCLUSIONS: The accuracy of prediction models using AI software to determine outcomes in OHCA was excellent and the AI-TOR rule's variables from prediction model performed better than the Universal TOR rule. External validation of our findings as well as further research into the utility of using AI platforms for TOR prediction in clinical practice is needed.

Efficacy of the shoelace technique for extremity fasciotomy wounds due to compartment syndrome.

BACKGROUND: The shoelace technique for compartment syndrome allows application of sustained tightening tension to an entire wound and intermittent tightening of the shoelace without requiring its replacement or anesthesia. We retrospectively evaluated the usefulness of the shoelace technique in the management of extremity fasciotomy wounds before and after its introduction in our institution. METHODS: We targeted 25 patients who were diagnosed as having compartment syndrome and underwent extremity fasciotomy at our hospital from April 2012 to December 2021. The N group, comprising 12 patients treated without the shoelace technique, and the S group, comprising 13 patients treated with the shoelace technique, were compared retrospectively for each outcome. RESULTS: There were no significant differences between the two groups in patient background. Compared with the N group patients, all of the S group patients avoided skin grafting (S group: n = 0, 0%; N group: n = 6, 50.0%; p < 0.01). However, there was no significant difference in the number of days to final wound closure (S group: 39.5 [IQR 24.3-58.0] days; N group: 24.0 [IQR 18.5-31.0] days, p = 0.06). CONCLUSIONS: We considered the shoelace technique to be a useful wound closure method for fasciotomy wounds caused by compartment syndrome because it can significantly reduce the need for skin grafting and tends to shorten the wound closure period.

Improved neurologically favorable survival after OHCA is associated with increased pre-hospital advanced airway management at the prefecture level in Japan.

Out-of-hospital cardiac arrest (OHCA) has high incidence and mortality. The survival benefit of pre-hospital advanced airway management (AAM) for OHCA remains controversial. In Japan, pre-hospital AAM are performed for OHCA by emergency medical services (EMS), however the relationship between resuscitation outcomes and AAM at the prefecture level has not been evaluated. The purpose of this study was to describe the association between AAM and neurologically favorable survival (cerebral performance category (CPC) ≦2) at prefecture level. This was a retrospective, population-based study of adult OHCA patients (≧ 18) from January 1, 2014 to December 31, 2017 in Japan. We excluded patients with EMS witnessed arrests. We also only included patients that had care provided by an ELST with the ability to provided AAM and excluded cases that involved prehospital care delivered by a physician. We categorized OHCA into four quartiles (four group: G1-G4) based on frequency of pre-hospital AAM approach rate by prefecture, which is the smallest geographical classification unit, and evaluated the relationship between frequency of pre-hospital AAM approach rates and CPC ≦ 2 for each quartile. Multivariable logistic regression was used to assess effectiveness of AAM on neurologically favorable survival. Among 493,577 OHCA cases, 403,707 matched our inclusion criteria. The number of CPC ≦ 2 survivors increased from G1 to G4 (p for trend < 0.001). In the adjusted multivariable regression, higher frequency of pre-hospital AAM approach was associated with CPC ≦ 2 (p < 0.001). High prefecture frequency of pre-hospital AAM approach was associated with neurologically favorable survival (CPC ≦ 2) in OHCA.

Lacosamide poisoning improved by hemodialysis.

Background: Lacosamide (LCM) is a third-generation antiepileptic drug that has been proven to be effective and safe, with few side-effects. Case Presentation: A woman aged in her 20s was transported to our hospital because of decreased consciousness. Many drugs, such as LCM (328 tablets) and perampanel hydrate (81 tablets), were found in her car. Her Glasgow Coma Scale score was 14. She was intubated and managed with mechanical ventilation, and she was treated with activated charcoal. Subsequently, hemodialysis (HD) was initiated due to the appearance of clonic convulsions. After 4 h of HD, no seizures were noted. The patient was weaned from the ventilator 18 h after admission and discharged on day 4. Her blood LCM level was 91.7 µg/mL on admission and 68.1 and 18.3 µg/ml before and after HD, respectively. Conclusion: Hemodialysis was carried out in this severe case of LCM poisoning and was found to be effective.

Kinetic study on solute permeation at the interface of molecular aggregates by partial filling capillary electrophoresis.

Moment analysis method using partial filling CE was developed for the kinetic study on solute permeation at the interface of spherical molecular aggregates. Moment equations for partial filling CE were developed by classifying CE systems into five categories according to the migration velocities of solute and molecular aggregate. The method was applied to the study on the dissolution of electrically neutral solutes into SDS micelles. Elution peaks were measured by partial filling CE while changing the concentration of SDS and the filling ratio of SDS micellar zone to the capillary (ϕM ). Partition equilibrium constants (Kp ) and rate constants of interfacial solute permeation of SDS micelles (kin and kout ) were determined from the first absolute and second central moments of the elution peaks by using the moment equations. Their values were comparable irrespective of ϕM and were almost the same as those previously measured by complete filling CE. The positive correlation of Kp with the hydrophobicity of the solutes was explained in terms of the change in kin and kout . It was demonstrated that the moment analysis method using partial filling CE is effective for studying solute permeation kinetics at the interface of spherical molecular aggregates.

Outcomes of patients with OHCA of presumed cardiac etiology that did not achieve prehospital restoration of spontaneous circulation: The All-Japan Utstein Registry experience.

BACKGROUND: Correct identification of futile prehospital resuscitation for out-of-hospital cardiac arrest (OHCA) may reduce unnecessary transports. Prehospital return of spontaneous circulation (ROSC) is considered by many to be an important predictor of outcome. The purpose of this study was to evaluate OHCA victims without prehospital ROSC characteristics and their outcomes in relation to the universal Termination of Resuscitation (TOR) rule. METHODS: A retrospective, population-based review of OHCA victims without prehospital ROSC from January 1, 2010 to December 31, 2017 in the All-Japan Utstein Registry. We compared those that met the universal TOR rule and those that did not for the primary outcome: one-month survival with neurologically favorable Cerebral Performance Category (CPC) 1 or 2. RESULTS: 989,929 OHCA cases, 18 years of age or older, were registered in the All-Japan Utstein Registry and 525,801 cases were of presumed cardiac origin and had no prehospital ROSC. Of these, the one-month CPC was 1 or 2 for 3957 cases (0.8%). In the 'no ROSC' group who also met the TOR rule, the number of cases was 433,571 with a one-month survival of 0.9% (3799 cases), and the proportion with a CPC 1or 2 was 0.2% (699 cases). CONCLUSIONS: Continued resuscitation and transport of cases with no field ROSC who fulfill the TOR rule is futile and could be considered for adoption in Japan.

Propofol suppresses ventricular arrhythmias: a case report of acute caffeine intoxication.

BACKGROUND: Caffeine is widely used as a stimulant drug throughout the world, and fatal arrhythmia is a known side-effect. We experienced a patient with caffeine intoxication causing fatal arrhythmias who was successfully treated with the infusion of propofol. CASE PRESENTATION: A 27-year-old woman was transferred to our hospital with nausea and poor general condition after intentional ingestion of 23.2 g of caffeine tablets. She was in cardiac arrest due to ventricular fibrillation just before hospital arrival. Advanced life support including defibrillation was started immediately, and we succeeded in resuscitating her 23 min later. Although she suffered from polymorphic ventricular premature beats and frequent transition to ventricular fibrillation, propofol administration converted her from a ventricular arrhythmia to sinus rhythm. CONCLUSION: We report this case focusing on the cardiovascular effects of propofol and the lipid sink phenomenon. As a result, propofol could have the potential to suppress ventricular arrhythmias.

A strategy for improving the prognosis of non-occlusive mesenteric ischemia (NOMI): a single-center observational study.

AIM: The purpose of this study was to determine the prognostic factors of non-occlusive mesenteric ischemia (NOMI) and to examine treatment strategies that could improve its prognosis. METHODS: We retrospectively identified 30 patients who underwent emergency laparotomy for NOMI in Kansai Medical University Hospital (Hirakata, Japan) from April 2013 to December 2017. We examined prognostic factors related to discharge outcome and also examined the prognostic impact of open abdominal management and second look operation strategy (OSS) by dividing the patients into the non-OSS group and the OSS group. RESULTS: The primary end-point was a prognostic factor for outcome at discharge of the 30 patients. The outcome at discharge was compared between the survival group and the death group. Multivariate analysis was undertaken on two items from the univariate analysis that showed a significant difference (computed tomography findings of intestinal pneumatosis and acute disseminated intravascular coagulation [DIC] score). As a result, there was a significant difference in the factors of intestinal pneumatosis (odds ratio = 0.054; 95% confidence interval, 0.005-0.607; P = 0.018) and DIC score (odds ratio = 1.892; 95% confidence interval, 1.077-3.323; P = 0.027). The secondary end-point was the treatment outcome before and after the application of OSS. Operation time was significantly shorter and the amount of bleeding was also significantly less in the OSS group. CONCLUSION: Computed tomography findings of intestinal pneumatosis and the acute disseminated intravascular coagulation score were found to be prognostic factors for survival in patients with NOMI. Aggressive laparotomy to determine the definitive diagnosis is needed and OSS could be useful to improve patient prognosis for survival from NOMI.

Ventricular septal perforation after blunt chest trauma due to blows from a fist.

Case: A 40-year-old man received fist blows to his chest and abdomen. He presented with external jugular vein distention and facial congestion. Chest X-ray showed bilateral pulmonary congestion. A Levine V/VI holosystolic murmur was audible. Echocardiography showed left-to-right shunt flow across the perimembranous region of the ventricular septum. The diameter of the hole was approximately 13 mm. We diagnosed ventricular septal perforation, started an infusion, and administered vasopressors. However, circulatory dynamics could not be maintained. The ventricular septal perforation was repaired directly with mattress sutures through the right ventricle. A small residual ventricular septal perforation was detected, which was repaired with a patch sutured through the left ventricle. Outcome: The patient was discharged without cardiovascular complications 43 days after admission. Conclusion: Ventricular septal perforation following blunt chest trauma is a rare form of cardiac trauma. It is important to consider the timing of the operation and the best method to ensure cardiac repair.

CD90-positive cells, an additional cell population, produce laminin alpha2 upon transplantation to dy(3k)/dy(3k) mice.

Laminin alpha2 is a component of skeletal and cardiac muscle basal lamina. A defect of the laminin alpha2 chain leads to severe congenital muscular dystrophy (MDC1A) in humans and dy/dy mice. Myogenic cells including myoblasts, myotubes, and myofibers in skeletal muscle are a possible source of the laminin alpha2 chain, and myogenic cells are thus proposed as a cell source for congenital muscular dystrophy therapy. However, we observed production of laminin alpha2 in non-myogenic cells of normal mice, and we could enrich these laminin alpha2-producing cells in CD90(+) cell fractions. Intriguingly, the number of CD90(+) cells increased dramatically during skeletal muscle regeneration in mice. This fraction did not include myogenic cells but exhibited a fibroblast-like phenotype. Moreover, these cells were resident in skeletal muscle, not derived from bone marrow. Finally, the production of laminin alpha2 in CD90(+) cells was not dependent on fusion with myogenic cells. Thus, CD90(+) cells are a newly identified additional cell fraction that increased during skeletal muscle regeneration in vivo and could be another cell source for therapy for lama2-deficient muscular dystrophy.