Low-Dose Continuous Kidney Replacement Therapy and Mortality in Critically Ill Patients With Acute Kidney Injury: A Retrospective Cohort Study.

RATIONALE & OBJECTIVE: Continuous kidney replacement therapy (CKRT) is preferred when available for hemodynamically unstable acute kidney injury (AKI) patients in the intensive care unit (ICU). The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend a delivered CKRT dose of 20-25mL/kg/h; however, in Japan the doses are typically below this recommendation due to government health insurance system restrictions. This study investigated the association between mortality and dose of CKRT. STUDY DESIGN: Single-center retrospective cohort study. SETTING & PARTICIPANTS: Critically ill patients with AKI treated with CKRT at a tertiary Japanese university hospital between January 1, 2012, and December 31, 2021. EXPOSURE: Delivered CKRT doses below or above the median. OUTCOME: 90-day mortality after CKRT initiation. ANALYTICAL APPROACH: Multivariable Cox regression analysis and Kaplan-Meier analysis. RESULTS: The study population consisted of 494 patients. The median age was 72 years, and 309 patients (62.6%) were men. Acute tubular injury was the leading cause of AKI, accounting for 81.8%. The median delivered CKRT dose was 13.2mL/kg/h. Among the study participants, 456 (92.3%) received delivered CKRT doses below 20mL/kg/h, and 204 (41.3%) died within 90 days after CKRT initiation. Multivariable Cox regression analysis revealed increased mortality in the below-median group (HR, 1.73 [95% CI, 1.19-2.51], P=0.004). Additionally, a significant, inverse, nonlinear association between 90-day mortality and delivered CKRT dose was observed using delivered CKRT dose as a continuous variable. LIMITATIONS: Single-center, retrospective, observational study. CONCLUSIONS: A lower delivered CKRT dose was independently associated with higher 90-day mortality among critically ill patients who mostly received dosing below the current KDIGO recommendations. PLAIN-LANGUAGE SUMMARY: The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend delivering a continuous kidney replacement therapy (CKRT) dose of 20-25mL/kg/h. However, it is not clear if it is safe to use delivered CKRT doses below this recommendation. In this study, over 90% of the patients received CKRT with a delivered dose below the KDIGO recommendation. We divided these patients into 2 groups based on the median delivered CKRT dose. Our findings show that a delivered CKRT dose below the median was associated with increased risk of death within 90 days. These findings show that a lower delivered CKRT dose was independently associated with higher 90-day mortality among critically ill patients who mostly received dosing below current KDIGO recommendations.

Fatal poisoning due to ingestion of boiled oleander leaf extract.

Nerium oleander is an ornamental evergreen shrub belonging to the family Apocynaceae. The Apocynaceae family includes the attractive evergreen shrub known as oleander. The cardiotoxic glycoside, oleandrin, is present in all portions of the common oleander plant. Oleander consumption can result in deadly situations accidentally or as a suicide attempt. After consuming kettle-boiled oleander leaf extract as part of a suicide attempt, an 80-year-old man was discovered comatose in his home and taken to our emergency room. The patient's heart rate was 30 beats per minute, and he had hypotension. Arterial blood gas analysis revealed remarkable metabolic acidosis and hyperkalemia (K: 7.7 mEq/L). An electrocardiogram showed a wide QRS wave, similar to a sine curve. The patient collapsed following cardiac arrest soon after hospital arrival. Veno-arterial extracorporeal membrane oxygenation was initiated; however, the patient eventually died. The serum level of oleandrin at hospital arrival, subsequently measured by LC-MS/MS, was found to be 33.4 ng/mL, far above the levels reported in previous fatal cases.

Recurrence of kyphotic deformity following implant removal in pediatric pure discoligamentous Chance-type injury: A case report.

Pediatric pure discoligamentous Chance-type injury is relatively rare and the appropriate surgical method has not yet been established, particularly, whether spinal fixation with fusion or without fusion is more effective. This case report describes a 10-year-old-boy who sustained an L2-3 pure discoligamentous Chance-type injury following a car accident and underwent an L2-3 posterior fixation without fusion. The implants were removed after eight months of an uneventful postoperative course. However, four months later, the kyphotic deformity recurred. Although the deformity gradually progressed over nine months, the patient remained neurologically intact and asymptomatic. This report suggests that fixation without fusion may not be appropriate in pediatric patients with pure discoligamentous Chance-type injuries. Spinal fixation with fusion may be recommended to prevent loss of correction and ensure secure stabilization.

The Combination of the Lactate Dehydrogenase/Hemoglobin Ratio with the PLASMIC Score Facilitates Differentiation of TTP from Septic DIC Without Identification of Schistocytes.

In some cases, differentiating thrombotic thrombocytopenic purpura (TTP) from septic disseminated intravascular coagulation (DIC) without measuring ADAMTS13 activity is critical for urgent lifesaving plasma exchange. To investigate whether PLASMIC score without identifying the presence of schistocytes, D-dimer, fibrin/fibrinogen degradation products (FDP), FDP/D-dimer ratio, prothrombin time-international normalized ratio (PT-INR), lactate dehydrogenase (LD), hemoglobin (Hb), and LD/Hb ratio are useful in differentiating patients with TTP from those with septic DIC. Retrospective analysis was conducted on the medical records of the patients with septic DIC (32 patients) or TTP (16 patients). The PLASMIC score and other laboratory measurements all were helpful in differentiating TTP from septic DIC. When dichotomized between high risk (scores 6-7) and intermediate-low risk (scores 0-5), the PLASMIC score predicted TTP with a sensitivity of 75.0% and a specificity of 100%. However, 4 of 16 patients with TTP and 19 of 32 patients with septic DIC showed comparable PLASMIC scores of 4 or 5, making it difficult to distinguish between the two by PLASMIC score alone. Among the measurements examined, the LDH/Hb ratio was the most useful for differentiation. Receiver operating characteristic analysis of the LD/Hb ratio for predicting TTP revealed a cutoff of 53.7 (IU/10 g) (sensitivity 0.94, specificity 0.91). If the LD/Hb ratio was less than 53.7, it was unlikely that the patient had TTP. A combination of the LD/Hb ratio and the PLASMIC score may be useful for distinguishing between TTP and DIC and identifying patients who need rapid plasma exchange or caplacizumab administration.

Explainable Prediction Model of the Need for Emergency Hemostasis Using Field Information During Physician-Staffed Helicopter Emergency Medical Service Interventions: A Single-Center, Retrospective, Observational Pilot Study.

OBJECTIVE: Early recognition of hemostasis is important to prevent trauma-related deaths. We conducted a pilot study of a predictive model of hemostatic need using factors that can be collected during helicopter emergency medical service (HEMS) interventions until transport hospital selection using cases from our institution. METHODS: This single-center, retrospective, observational pilot study included 251 trauma patients aged ≥ 18 years treated with HEMS between April 2017 and March 2022, in Nara Medical University. Cardiac arrest and pre-HEMS treatment patients were excluded. Emergency hemostatic surgery prediction models were constructed using the light gradient boosting machine cross-validation method using objective data that could be collected before hospital determination. The accuracy of this model was compared with that of the ground emergency medical service-based model, and factors influencing outcome were visualized using Shapley additive explanations. RESULTS: The predictive accuracy of the model with HEMS intervention factors was an area under the receiver operating characteristic curve of 0.80, superior to the 0.73 accuracy area under the receiver operating characteristic curve for ground emergency medical services constructed with contact information. Clinically important factors, such as shock index, blood pressure changes, and ultrasound findings, had a significant impact on outcomes, with nonmonotonic effects observed across factors. CONCLUSION: This pilot study suggests that predictive models of emergency hemostasis can be built using limited prehospital information. To validate this model, a larger, multicenter study is recommended.

A novel radiological assessment to identify acute vertebral compression fractures: A pilot observational study.

Aim: The diagnosis of acute vertebral compression fractures (AVCFs) is often challenging. An alternative to magnetic resonance imaging, which may not always be available, includes a comparison of supine and sitting/standing position radiographs. However, this cannot be accomplished in patients with acute vertebral compression fractures who require emergency transport and are in severe pain. In this study, aimed to assess the diagnostic accuracy of comparing lateral-view radiographs of the thoracolumbar spine in supine and 30° head-elevated positions, which are less painful. Methods: We retrospectively examined 30 patients with AVCFs who were transported by ambulance to our emergency department between June 2018 and May 2019. All underwent 30° head-elevated lateral-view thoracolumbar spine radiography and magnetic resonance imaging. We evaluated vertebral fractures by examining changes in vertebral wedging ratio (WR) from supine to 30° head-elevated position (Δ WR) using the following equation: Δ WR = WR (30° head-elevated) - WR (supine). We compared Δ WR to that of unfractured vertebrae as control. Results: A total of 176 vertebrae were included (fractured, 32 and non-fractured, 144). Δ WR of fractured vertebrae ranged between 5.1% and 24.4%, whereas non-fractured vertebrae ranged between -6.7% and 4.3%. Median Δ WR of fractured vertebrae was significantly higher than non-fractured vertebrae (12.6% versus -0.5%, p < 0.001). No patients reported pain during 30° head-elevated positioning. Conclusions: Lateral radiographs in supine and 30° head-elevated positions can accurately diagnose of AVCF, without worsening pain. This study showed a Δ WR value of ≥5.1% for AVCFs.

Machine learning-based analysis of regional differences in out-of-hospital cardiopulmonary arrest outcomes and resuscitation interventions in Japan.

Refining out-of-hospital cardiopulmonary arrest (OHCA) resuscitation protocols for local emergency practices is vital. The lack of comprehensive evaluation methods for individualized protocols impedes targeted improvements. Thus, we employed machine learning to assess emergency medical service (EMS) records for examining regional disparities in time reduction strategies. In this retrospective study, we examined Japanese EMS records and neurological outcomes from 2015 to 2020 using nationwide data. We included patients aged ≥ 18 years with cardiogenic OHCA and visualized EMS activity time variations across prefectures. A five-layer neural network generated a neurological outcome predictive model that was trained on 80% of the data and tested on the remaining 20%. We evaluated interventions associated with changes in prognosis by simulating these changes after adjusting for time factors, including EMS contact to hospital arrival and initial defibrillation or drug administration. The study encompassed 460,540 patients, with the model's area under the curve and accuracy being 0.96 and 0.95, respectively. Reducing transport time and defibrillation improved outcomes universally, while combining transport time and drug administration showed varied efficacy. In conclusion, the association of emergency activity time with neurological outcomes varied across Japanese prefectures, suggesting the need to set targets for reducing activity time in localized emergency protocols.

Recurrent ventricular arrhythmia due to aconite intoxication successfully treated with landiolol: A case report.

BACKGROUND: Ventricular arrhythmias, such as ventricular tachycardia and fibrillation, are the main causes of death in patients with aconite poisoning. CASE SUMMARY: A 51-year-old man presented to our emergency department because he was vomiting after ingesting aconite root to attempt suicide. On arrival, the patient was hemodynamically unstable, and his electrocardiogram revealed polymorphic ventricular extrasystoles and non-sustained ventricular tachycardia. Amiodarone was immediately administered for ventricular arrhythmia. However, the patient remained unresponsive. We administered continuous intravenous landiolol as the ventricular arrhythmia worsened, gradually suppressing it. The patient returned to sinus rhythm 16 h after arriving at the hospital. Some aconitum alkaloids act on voltage-gated Na+- channels and induce ventricular or supraventricular tachyarrhythmias. Landiolol suppresses sympathetic nerve activity through its blocking effect, preventing arrhythmia. CONCLUSION: Landiolol can be a therapeutic option for amiodarone-refractory ventricular arrhythmias caused by aconite intoxication.

The First Case in Japan of Fulminant Myocarditis Due to Multisystem Inflammatory Syndrome in Children (MIS-C) That Required Mechanical Circulatory Support.

Multisystem inflammatory syndrome in children (MIS-C) is a novel hyperinflammatory syndrome that is associated with severe acute respiratory syndrome coronavirus 2 infections. Reports describing the mechanical circulatory support (MCS) and myocardial biopsy for fulminant myocarditis due to MIS-C are limited.A 13-year-old male patient with MIS-C underwent treatment, including immunosuppressive therapy and MCS devices, and managed to recover from pulseless electrical activity cardiac arrest.This is the first patient in Japan with MIS-C who required MCS devices in Japan. Appropriate and immediate treatment with immunosuppressive therapy and MCS devices is important.

Explainable artificial intelligence-based prediction of poor neurological outcome from head computed tomography in the immediate post-resuscitation phase.

Predicting poor neurological outcomes after resuscitation is important for planning treatment strategies. We constructed an explainable artificial intelligence-based prognostic model using head computed tomography (CT) scans taken immediately within 3 h of resuscitation from cardiac arrest and compared its predictive accuracy with that of previous methods using gray-to-white matter ratio (GWR). We included 321 consecutive patients admitted to our institution after resuscitation for out-of-hospital cardiopulmonary arrest with circulation resumption over 6 years. A machine learning model using head CT images with transfer learning was used to predict the neurological outcomes at 1 month. These predictions were compared with the predictions of GWR for multiple regions of interest in head CT using receiver operating characteristic (ROC)-area under curve (AUC) and precision recall (PR)-AUC. The regions of focus were visualized using a heatmap. Both methods had similar ROC-AUCs, but the machine learning model had a higher PR-AUC (0.73 vs. 0.58). The machine learning-focused area of interest for classification was the boundary between gray and white matter, which overlapped with the area of focus when diagnosing hypoxic- ischemic brain injury. The machine learning model for predicting poor outcomes had superior accuracy to conventional methods and could help optimize treatment.

Factors associated with the increased risk of atlantoaxial osteoarthritis: a retrospective study.

Purpose Atlantodens osteoarthritis and atlantoaxial osteoarthritis cause neck pain and suboccipital headaches. Currently, knowledge on the risk factors for atlantoaxial osteoarthritis is lacking. This study aimed to investigate the factors related to the increased risk of atlantoaxial osteoarthritis. Methods We analyzed computed tomography (CT) images of the upper cervical spine of 1266 adult trauma patients for whom upper cervical spine CT was performed at our hospital between 2014 and 2019. The degree of atlantoaxial osteoarthritis was quantified as none-to-mild (not having osteoarthritis) or moderate-to-severe (having osteoarthritis). Risk factors associated with atlantoaxial osteoarthritis were identified using univariate and multivariable logistic regression analyses. Results The study group included 69.4% men, and the overall average age of the study population was 54.9 ± 20.4 years. The following factors were independently and significantly associated with atlantoaxial osteoarthritis in the multivariable logistic regression analysis: age in the sixth decade or older (odds ratio [OR], 20.5; 95% confidence interval [CI], 6.2‒67.2, p < 0.001), having calcific synovitis (OR, 4.9; 95% CI, 2.4‒9.9, p < 0.001), women sex (OR, 3.3; 95% CI, 1.9‒5.7, p = 0.002), and not having atlantodens osteoarthritis (OR, 2.1; 95% CI, 1.2‒3.8, p = 0.014). Conclusion In the multivariable logistic regression analysis, age in the sixth decade or older, calcification of the transverse ligament, being women, and not having atlantodens osteoarthritis were found to be significantly associated with atlantoaxial osteoarthritis. Delayed diagnosis and treatment can be avoided by focusing on these risk factors.

Sensitivity and specificity analyses of COVID-19 screening protocol for emergency medical services: A STARD-compliant population-based retrospective study.

During the novel coronavirus disease (COVID-19) pandemic, emergency medical services (EMS) has borne a huge burden in transporting emergency patients. However, the protocol's effect on identifying emergency patients who are likely to have COVID-19 is unknown. We aimed to evaluate the diagnostic accuracy of a prehospital COVID-19 screening protocol for EMS. We conducted this population-based retrospective study in Nara Prefecture, Japan. The Nara Prefectural Government implemented a screening protocol for COVID-19 comprising the following symptom criteria (fever, cough, sore throat, headache, malaise, dysgeusia, or anosmia) and epidemiological criteria (contact history with confirmed COVID-19 cases or people with upper respiratory symptoms, or travel to areas with high infection rate). A patient meeting at least one criterion of each class was considered positive. We evaluated all 51,351 patients from the regional EMS database of the Nara Prefecture (emergency Medical Alliance for Total Coordination of Healthcare) who were registered from June 15, 2020 to May 31, 2021 and had results of COVID-19 reverse transcription polymerase chain reaction (RT-PCR) tests. We assessed the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of this protocol. We also assessed how these outcomes changed by adding vital signs and conducted a 10-fold and 100-fold prevalence simulation. The screening protocol was used for 246/51351 patients (0.5%). Among them, 31 tested positive after EMS transportation. This protocol's sensitivity, specificity, PPV, and NPV were 40.8%, 99.6%, 12.6%, and 99.9%, respectively. With the addition of ≥2 vital signs (body temperature ≥37.5 °C, respiratory rate ≥20 breaths/minute, and oxygen saturation <90%), sensitivity and PPV changed to 61.8% and 1.0%, respectively, while NPV remained 99.9%. With a 10-fold and 100-fold increase in disease, the protocol PPV would be 59.0% and 94.3%, and NPV would be 99.1% and 90.7%, respectively, and with additional vital signs, PPV would be 8.9% and 53.1%, and NPV would be 99.4% and 93.2%, respectively. This COVID-19 screening protocol helped enable EMS transport for patients with COVID-19 with a PPV of 12.6%. Adding other vital sign variables may improve its diagnostic value if the prevalence rate increases.

Visual assessment of interactions among resuscitation activity factors in out-of-hospital cardiopulmonary arrest using a machine learning model.

AIM: The evaluation of the effects of resuscitation activity factors on the outcome of out-of-hospital cardiopulmonary arrest (OHCA) requires consideration of the interactions among these factors. To improve OHCA success rates, this study assessed the prognostic interactions resulting from simultaneously modifying two prehospital factors using a trained machine learning model. METHODS: We enrolled 8274 OHCA patients resuscitated by emergency medical services (EMS) in Nara prefecture, Japan, with a unified activity protocol between January 2010 and December 2018; patients younger than 18 and those with noncardiogenic cardiopulmonary arrest were excluded. Next, a three-layer neural network model was constructed to predict the cerebral performance category score of 1 or 2 at one month based on 24 features of prehospital EMS activity. Using this model, we evaluated the prognostic impact of continuously and simultaneously varying the transport time and the defibrillation or drug-administration time in the test data based on heatmaps. RESULTS: The average class sensitivity of the prognostic model was more than 0.86, with a full area under the receiver operating characteristics curve of 0.94 (95% confidence interval of 0.92-0.96). By adjusting the two time factors simultaneously, a nonlinear interaction was obtained between the two adjustments, instead of a linear prediction of the outcome. CONCLUSION: Modifications to the parameters using a machine-learning-based prognostic model indicated an interaction among the prognostic factors. These findings could be used to evaluate which factors should be prioritized to reduce time in the trained region of machine learning in order to improve EMS activities.

Factors associated with EMS on-scene time and its regional difference in road traffic injuries: a population-based observational study.

BACKGROUND: The outcome of road traffic injury (RTI) is determined by duration of prehospital time, patient's demographics, and the type of injury and its mechanism. During the emergency medical service (EMS) prehospital time interval, on-scene time should be minimized for early treatment. This study aimed to examine the factors influencing on-scene EMS time among RTI patients. METHODS: We evaluated 19,141 cases of traffic trauma recorded between April 2014 and March 2020 in the EMS database of the Nara Wide Area Fire Department and the prehospital database of the emergency Medical Alliance for Total Coordination of Healthcare (e-MATCH). To examine the association of the number of EMS phone calls until hospital acceptance, age ≥65 years, high-risk injury, vital signs, holiday, and nighttime (0:00-8:00) with on-scene time, a generalized linear mixed model with random effects for four study regions was conducted. RESULTS: EMS phone calls were the biggest factor, accounting for 5.69 minutes per call, and high-risk injury accounted for an additional 2.78 minutes. Holiday, nighttime, and age ≥65 years were also associated with increased on-scene time, but there were no significant vital sign variables for on-scene time, except for the level of consciousness. Regional differences were also noted based on random effects, with a maximum difference of 2 minutes among regions. CONCLUSIONS: The number of EMS phone calls until hospital acceptance was the most significant influencing factor in reducing on-scene time, and high-risk injury accounted for up to an additional 2.78 minutes. Considering these factors, including regional differences, can help improve the regional EMS policies and outcomes of RTI patients.

Effect of Coaching with Repetitive Verbal Encouragements on Dispatch-Assisted Cardiopulmonary Resuscitation: A Randomized Simulation Study.

BACKGROUND: Current guidelines emphasize the assistance of the emergency dispatcher in bystander cardiopulmonary resusitation (CPR). Its quality, however, has varied across cases. OBJECTIVE: To determine the effect of repetitive coaching by dispatchers using verbal encouragement on the quality of lay-rescuer CPR. METHODS: We conducted a dispatch-assisted CPR (DACPR) simulation study. Participants with no CPR training within the previous year were assigned randomly to 1 of 2 DACPR simulations. One was the No Coaching Group: callers were told to perform CPR and the dispatcher periodically confirmed that the caller was performing CPR. The second group was the Coaching Group: the dispatcher repetitively coached, encouraged, and counted aloud using a metronome. Participants performed CPR for 2 min under instruction from the study dispatcher. Parameters including chest compression depth, rate, and chest compression fraction were recorded by video camera and CPR manikin. RESULTS: Forty-nine participants 20 to 50 years of age were recruited, and 48 completed the simulation (Coaching Group, n = 27; No Coaching Group, n = 21). The chest compression fraction was higher in the Coaching Group (99.4% vs. 93.0%, p = 0.005) and no participants interrupted chest compression more than 10 s in this group. When comparing the average depth of each 30-s period in each group, the depth increased over time in the Coaching Group (40.9 mm, 43.9 mm, 44.1 mm, and 42.8 mm), while it slightly decreased in the No Coaching Group (40.6 mm, 40.1 mm, 39.4 mm, and 39.8 mm). CONCLUSIONS: Repetitive verbal encouragements augmented chest compression depth with less-hands off time. Continuous coaching by dispatchers can optimize lay-rescuer CPR. © 2022 Elsevier Inc.

Association of multiple rib fractures with the frequency of pneumonia in the post-resuscitation period.

Purpose: Successful cardiopulmonary resuscitation is associated with a high incidence of chest wall injuries. However, few studies have examined chest wall injury as a risk factor for respiratory complications after cardiopulmonary resuscitation. Therefore, herein, we investigated the association of multiple rib fractures on the incidence of post-resuscitation pneumonia. Methods: This single-centre retrospective cohort study enrolled adult, nontraumatic, out-of-hospital cardiac arrest patients who maintained circulation for more than 48 h between June 2015 and May 2019. Rib fractures were evaluated by computed tomography on the day of hospital admission. The association with newly developed pneumonia within 7 days of hospitalisation was analysed using a Fine-Gray proportional hazards regression model adjusted for the propensity score of multiple rib fractures estimated from age, sex, presence of witnessed status, bystander CPR, initial rhythm, and total CPR time and for previously reported risk factors for pneumonia (therapeutic hypothermia and prophylactic antibiotics). Results: Overall, 683 patients with out-of-hospital cardiac arrest were treated; 87 eligible cases were enrolled for analysis. Thirty-two (36.8%) patients had multiple rib fractures identified on computed tomography, and 35 (40.2%) patients developed pneumonia. The presence of multiple rib fractures was significantly associated with a higher incidence of pneumonia, consistently both with and without adjustment for background factors (unadjusted hazard ratio 4.63, 95% confidence interval: 2.35-9.13, p < 0.001; adjusted hazard ratio 4.03, 95% confidence interval: 2.08-7.82, p < 0.001). Conclusions: Multiple rib fractures are independently associated with the development of pneumonia after successful resuscitation.

Comparison of Changes in Vital Signs During Ground and Helicopter Emergency Medical Services and Hospital Interventions.

OBJECTIVE: Few studies have evaluated the effects of helicopter emergency medical services (HEMS) alone. This single-center study compared the changes in vital signs during ground emergency medical services (GEMS), HEMS, and hospital interventions to assess the impact of HEMS interventions. METHODS: This retrospective observational study included 168 trauma patients older than 18 years of age who received HEMS. Patients with cardiac arrest or those who received medical attention before HEMS were excluded. We assessed 3 intervention phases (GEMS, HEMS, and hospital). The changes in heart rate, systolic blood pressure, respiratory rate, and shock index in response to interventions were calculated and divided by the intervention time, and the changes observed during the interventions were compared. RESULTS: No changes in vital signs were observed when receiving GEMS. Systolic blood pressure increased and shock index decreased after HEMS, whereas systolic blood pressure decreased and shock index increased during hospital interventions. Heart rate showed no significant change (P = .12), and respiratory rate showed very little change. Systolic blood pressure increased significantly during HEMS compared with the pre- and postintervention periods. CONCLUSION: Changes in vital signs differed according to the intervention. Systolic blood pressure increased during HEMS but not with GEMS or hospital interventions.

The balance of comprehensive coagulation and fibrinolytic potential is disrupted in patients with moderate to severe COVID-19.

Coagulation and fibrinolytic mechanisms are enhanced in patients with coronavirus (COVID-19), but disturbances in the balance of both functions in COVID-19 patients remain unclear. We assessed global coagulation and fibrinolysis in plasma from 167 COVID-19 patients (mild/moderate/severe: 62/88/17, respectively) on admission using clot-fibrinolysis waveform analysis (CFWA). Maximum coagulation velocity (|min1|) and maximum fibrinolysis velocity (|FL-min1|) were expressed as ratios relative to normal plasma. Ten patients (6.0%) developed thrombosis, 5 (3.0%) had bleeding tendency, and 13 (7.8%) died during admission. FDP levels increased with severity of COVID-19 symptoms (mild/moderate/severe; median 2.7/4.9/9.9 µg/mL, respectively). The |min1| ratios were elevated in all categories (1.27/1.61/1.58) in keeping with enhanced coagulation potential, with significant differences between mild cases and moderate to severe cases. The |FL-min1| ratios were also elevated in all groups (1.19/1.39/1.40), reflecting enhanced fibrinolytic potential. These data identified coagulation dominance in moderate to severe cases, but balanced coagulation and fibrinolysis in mild cases. There were significant differences in FDP and TAT, but no significant differences in |min1| or |FL-min1| ratios, between patients with and without thrombosis. CFWA monitoring of coagulation and fibrinolysis dynamics could provide valuable data for understanding hemostatic changes and disease status in COVID-19 patients.

Minimally invasive 360-degree pelvic ring fixation using a combination of crab-shaped fixation and pelvic internal fixator for unstable pelvic ring fracture: A case report.

Surgery with both anterior and posterior fixation is recommended for unstable pelvic ring fractures; nonetheless, the surgical method remains controversial. Crab-shaped fixation is a minimally invasive and strong posterior fixation method using spinal instruments that can reduce vertical dislocations. The use of pelvic internal fixator as a minimally invasive anterior fixation method has been reported. It is recommended in cases where there is an open wound in the lower abdomen or damage to the pelvic organs. Conversely, to the best of our knowledge, there has been no report on the combined use of crab-shaped fixation and pelvic internal fixator to date. We performed a minimally invasive 360-degree fixation using a combination of crab-shaped fixation and pelvic internal fixator for an unstable pelvic ring fracture (AO-C2) and sacral fracture (Denis zone II) with 15-mm vertical dislocation. The sacral fracture was accompanied by a large bone fragment in the spinal canal, which was suspected to have caused neuropathy. Therefore, in addition to posterior fixation, we performed decompression and removed the bone fragment. Postoperative computed tomography revealed that the sacral vertical dislocation was reduced to 7.5 mm. The patient started getting out of bed on postoperative day 2. His neuropathy improved after surgery. Owing to abdominal discomfort, pelvic internal fixator was extracted at 3 months postoperatively. Bone fusion was completed, and posterior fixation was removed at 9 months postoperatively. Two years after, the patient walks independently and has returned to work. Minimally invasive 360-degree pelvic ring fixation is a treatment option for an unstable pelvic ring fracture (AO-C2).

A new quantitative assessment method for predicting pneumonia caused by chest wall injury.

BACKGROUND: The severity of rib fractures has been previously evaluated by combining categorical data, but these methods have only low predictive capability for respiratory complications and mortality. This study aimed to establish a more accurate method for predicting the development of pneumonia, a frequent complication in chest injuries, using anatomical relationships. METHODS: We analyzed three-dimensional reconstructed images of 644 consecutive trauma patients who underwent whole-body computed tomography (CT) in our institution within a 36-month study period from April 2017. The anatomical relationship between the right and left thoracic volumes of non-rib fracture patients was used to estimate thoracic volume changes on the injured side in unilateral rib fracture patients. The predictive capability of changes in thoracic volume for the development of pneumonia was evaluated according to the area under the receiver operating characteristic curve and compared with that of previous chest wall severity evaluation methods. RESULTS: Of the 644 patients, 133 and 478 patients had unilateral rib fractures and non-rib fractures, respectively. The amount of change in thoracic volume due to unilateral rib fractures was significantly greater in pneumonia patients (400 mL vs. 160 mL, p < 0.01). The area under the receiver operating characteristic curve for the development of pneumonia was 0.83, which tended to be higher than that of the previous severity scoring methods. CONCLUSION: The amount of change in chest volume, which can be estimated using CT images, has better predictive capability for pneumonia than previous severity assessment methods based on categorical data. The amount of change in chest volume measured using whole-body CT can be used to rapidly determine the optimal treatment for severe chest wall injuries. LEVEL OF EVIDENCE: Prognostic study, level IV.