Association of Contrast Extravasation Grade With Massive Transfusion in Pediatric Blunt Liver and Spleen Injuries: A Multicenter Retrospective Cohort Study.

BACKGROUND: This study aimed to assess whether the grade of contrast extravasation (CE) on CT scans was associated with massive transfusion (MT) requirements in pediatric blunt liver and/or spleen injuries (BLSI). METHODS: This multicenter retrospective cohort study included pediatric patients (≤16 years old) who sustained BLSI between 2008 and 2019. MT was defined as transfusion of all blood products ≥40 mL/kg within the first 24 h of admission. Associations between CE and MT requirements were assessed using multivariate logistic regression analysis with cluster-adjusted robust standard errors to calculate the adjusted odds ratio (AOR). RESULTS: A total of 1407 children (median age: 9 years) from 83 institutions were included in the analysis. Overall, 199 patients (14 %) received MT. CT on admission revealed that 54 patients (3.8 %) had CE within the subcapsular hematoma, 100 patients (7.1 %) had intraparenchymal CE, and 86 patients (6.1 %) had CE into the peritoneal cavity among the overall cohort. Multivariate analysis, adjusted for age, sex, age-adjusted shock index, injury severity, and laboratory and imaging factors, showed that intraparenchymal CE and CE into the peritoneal cavity were significantly associated with the need for MT (AOR: 2.50; 95 % CI, 1.50-4.16 and AOR: 4.98; 95 % CI, 2.75-9.02, respectively both p < 0.001). The latter significant association persisted in the subgroup of patients with spleen and liver injuries. CONCLUSION: Active CE into the free peritoneal cavity on admission CT was independently associated with a greater probability of receiving MT in pediatric BLSI. The CE grade may help clinicians plan blood transfusion strategies. LEVEL OF EVIDENCE: Level 4; Therapeutic/Care management.

Social Isolation/Loneliness and Tooth Loss in Community-Dwelling Older Adults: The Sukagawa Study.

Background and Objectives: The relationship between social isolation/loneliness and oral health is unclear. This study investigated the association between social isolation/loneliness and tooth loss in older Japanese adults. Research Design and Methods: This was a cross-sectional study of a population-based cohort (the Sukagawa Study); 5,490 cohort study participants aged ≥75 years and who were independent answered a self-administered questionnaire in 2018. Social isolation was defined based on the 6-item Japanese version of the Lubben Social Network Scale. Loneliness was measured by the 3-item Japanese version of the University of California, Los Angeles (UCLA) Loneliness Scale version 3. The primary outcome was tooth loss, defined as having fewer than 20 teeth. The secondary outcomes were decreased toothbrushing frequency and diminished ability to chew food. Prevalence ratios (PRs) were estimated using a modified Poisson regression analysis in 2 models-Model 1, which adjusted for age, gender, smoking status, alcohol consumption, low annual income, and short education period, and Model 2, which added history of depression, history of diabetes mellitus, history of stroke, and cognitive impairment to Model 1. Results: The primary analysis included 4,645 participants. Adjusted PRs of social isolation and loneliness for tooth loss (Model 1) were 0.97 (95% confidence interval [CI] 0.92-1.01) and 1.06 (95% CI 1.01-1.12), respectively; those for decreased toothbrushing frequency were 1.13 (95% CI 0.95-1.36) and 1.56 (95% CI 1.26-1.92), respectively; and those for chewing difficulty were 1.61 (95% CI 1.06-2.43) and 2.94 (95% CI 1.91-4.53), respectively. The adjusted PRs in Model 2 demonstrated results similar to that of Model 1. Discussion and Implications: Loneliness is associated with tooth loss among older adults, whereas social isolation is not. Our findings can inform plans for policymakers, professionals, and organizations to identify lonely older adults and provide social prescriptions to improve their access to oral health care services.

Gestational weight gain as a risk factor for dystocia during first delivery: a multicenter retrospective cohort study in Japan.

BACKGROUND: Dystocia is a common obstetric complication among nulliparous women, which requires medical intervention and carries the risk of negative maternal and neonatal outcomes. Our aim was to examine the association between body mass index (BMI) and the occurrence of dystocia. We also identified cutoffs of gestational weight gain, based on pre-pregnancy BMI, associated with the risk of dystocia. METHODS: This was a multicenter, retrospective, cohort study conducted in two tertiary Maternal-Fetal medicine units in Fukushima, Japan. The study population included nullipara women who delivered at either of the two units between January 1, 2013, and December 31, 2020. Women (n = 2597) were categorized into six groups (G) based on their pre-pregnancy BMI: G1 (< 18.5 kg/m2), G2 (18.5 to < 20.0 kg/m2), G3 (20.0 to < 23.0 kg/m2), G4 (23.0 to < 25.0 kg/m2), G5 (25.0 to < 30.0 kg/m2), and G6 (≥ 30.0 kg/m2). Using G3 as a reference, multiple logistic regression analyses were performed to estimate the risk of dystocia for each BMI category. Receiver operating characteristic curve analyses were performed to determine the cutoff value of gestational weight gain for the risk of dystocia. RESULTS: The highest BMI category (G6) was an independent risk factor for dystocia (adjusted odds ratio, 3.0; 95% confidence interval, 1.5-5.8). The receiver operating characteristic curve analysis revealed no association between gestational weight gain and the occurrence of dystocia in G5 and G6 (P = 0.446 and P = 0.291, respectively). For G1 to G4, AUC and predictive cutoffs of gestational weight gain for dystocia were as follows: G1, AUC 0.64 and cutoff 11.5 kg (P < 0.05); G2, AUC 0.63 and cutoff 12.3 kg (P < 0.05); G3, AUC 0.67 and cutoff 14.3 kg (P < 0.01); and G4, AUC 0.63 and cutoff 11.5 kg (P < 0.05). CONCLUSION: A pre-pregnancy BMI > 30.0 kg/m2 was an independent risk factor for dystocia. For women with a pre-pregnancy BMI < 25.0 kg/m2, the risk of dystocia increases as a function of gestational weight gain. These findings could inform personalized preconception care for women to optimize maternal and neonatal health.

Associations between low body mass index and mortality in patients with sepsis: A retrospective analysis of a cohort study in Japan.

BACKGROUND: The distribution of body mass in populations of Western countries differs from that of populations of East Asian countries. In East Asian countries, fewer people have a high body mass index than those in Western countries. In Japan, the country with the highest number of older adults worldwide, many people have a low body mass index. Therefore, this study aimed to determine the association between a low body mass index and mortality in patients with sepsis in Japan. METHODS: We conducted this retrospective analysis of 548 patients with severe sepsis from a multicenter prospective observational study. Multivariate logistic regression analyses determined the association between body mass index and 28-day mortality adjusted for age, sex, pre-existing conditions, the occurrence of septic shock, Acute Physiology and Chronic Health Evaluation II scores, and Sequential Organ Failure Assessment scores. Furthermore, the association between a low body mass index and 28-day mortality was analyzed. RESULTS: The low body mass index group represented 18.8% of the study population (103/548); the normal body mass index group, 57.3% (314/548); and the high body mass index group, 23.9% (131/548), with the 28-day mortality rates being 21.4% (22/103), 11.2% (35/314), and 14.5% (19/131), respectively. In the low body mass index group, the crude and adjusted odds ratios (95% confidence intervals) for 28-day mortality relative to the non-low body mass index (normal and high body mass index groups combined) group were 2.0 (1.1-3.4) and 2.3 (1.2-4.2), respectively. CONCLUSION: A low body mass index was found to be associated with a higher 28-day mortality than the non-low body mass index in patients with sepsis in Japan. Given that older adults often have a low body mass index, these patients should be monitored closely to reduce the occurrence of negative outcomes.

Significance of Overactive Bladder as a Predictor of Falls in Community Dwelling Older Adults: 1-Year Followup of the Sukagawa Study.

PURPOSE: Little is known about the fall risk of older adults with overactive bladder, especially in the absence of urgency incontinence. We evaluated the impacts of overactive bladder with and without urgency incontinence (overactive bladder wet and overactive bladder dry) on the fall risk in older adults, and investigated the importance of overactive bladder as a predictor of falls by using tree based models. MATERIALS AND METHODS: This prospective cohort study included 630 community dwelling, independent older adults 75 years old or older who attended a health checkup in 2017 with a 1-year followup. The associations of overactive bladder dry and overactive bladder wet with a fall history, and future fall risk compared to no overactive bladder were assessed using logistic regression models. The contribution of overactive bladder as a predictor of falls was examined using a random forest and decision tree approach. RESULTS: Of the 577 analyzed participants (median age 79 years), 273 (47%) were men. The prevalence of overactive bladder dry and overactive bladder wet at baseline was 15% and 14%, respectively. Multivariable logistic regression analysis revealed that both overactive bladder dry and overactive bladder wet were associated with a higher likelihood of prior falls (adjusted ORs vs no overactive bladder 2.03 and 2.21, respectively; 95% CI 1.23-3.37 and 1.29-3.78, respectively). Among the 363 participants without a fall history, the adjusted ORs (95% CIs) of overactive bladder dry and overactive bladder wet for the occurrence of falls during the 1-year followup were 2.74 (1.19-6.29) and 1.35 (0.47-3.87), respectively. The tree based approach used for all participants showed that overactive bladder was an important predictor of falls in adults without a fall history, and the model had 83.6% accuracy and 81.8% AUC. CONCLUSIONS: Overactive bladder, even in the absence of urgency incontinence, is an important predictor of falls in older adults with a low absolute fall risk.

Vehicle configurations associated with anatomical-specific severe injuries resulting from traffic collisions.

Vehicles can be classified by configuration as either bonnet-type or cab-over type according to engine location. Compared to bonnet-type, the front compartment of cab-over type vehicles is considerably shorter; thus, it may be less likely to absorb the energy generated in a collision, and in turn be unable to prevent deformation of the occupant space and protect occupants from injury. This study was a cohort study involving 943 occupants of mini-vehicles who were injured in frontal collision accidents between 2001 and 2015 and transferred to Ohta Nishinouchi Hospital. The vehicle configuration was divided into bonnet-type and cab-over type (i.e., truck-type and wagon-type). The tested outcomes were anatomical-specific severe injury of the pelvis and extremities, the head and neck, the abdomen, and the chest. To estimate adjusted odds ratios (AOR) for associations between vehicle configuration and anatomical-specific severe injury, we fitted generalized estimating equations for each outcome. Compared with bonnet-type vehicles, a greater risk of serious pelvis and extremities injury was found for both truck (AOR: 2.21; 95% Confidence Interval [95% CI]: 1.22-4.00) and wagon-type vehicles (AOR: 3.43; 95%CI 1.60-7.39). For serious head and neck injury, truck-type vehicles were associated with greater risk (AOR: 2.04; 95% CI: 1.10-3.79) than bonnet-type vehicles, whereas wagon-type vehicles were not. Compared with the occupants of bonnet-type vehicles, cab-over type vehicle occupants were more likely to have serious pelvis and extremities injury during frontal collisions. Additionally, truck-type vehicle occupants were more likely to have serious head and neck injury than bonnet-type vehicle occupants. These findings are expected to promote safer behaviors for vehicle occupants and the automobile industry.

Gait speed and overactive bladder in the healthy community-dwelling super elderly: The Sukagawa Study.

AIM: The objective of this study is to assess the association of muscle mass, grip strength, and gait speed with overactive bladder (OAB) in community-dwelling elderly adults. METHODS: This cross-sectional study was based on the data collected from 350 Japanese healthy community-dwelling elderly individuals aged 75 years or older from the Sukagawa Study. Muscle mass (kg) was measured by bioelectrical impedance, whereas grip strength (kg) and gait speed (m/s) were measured by performance testing. Muscle mass and grip strength were corrected for body mass index (BMI). The primary outcome was the presence of OAB, evaluated using the OAB symptom score. RESULTS: Of the 314 participants analyzed, 146 (47%) were men and 88 (28%) presented with OAB. The mean (SD) BMI, muscle mass, grip strength, and gait speed were 23.2 (3.2) kg/m 2 , 38.4 (7.5) kg, 26.6 (8.1) kg, and 1.2 (0.2) m/s, respectively. Multivariable logistic regression analysis revealed that slower gait speed was associated with a greater likelihood of OAB (adjusted odds ratio [aOR] per -1 SD, 1.47; 95% confidence interval [CI], 1.11-1.95). No significant associations between muscle mass or grip strength and OAB were noted (aOR per -1 SD, 0.75, 1.03; 95% CI, 0.41-1.37, 0.62-1.72, respectively). Slower gait speed was also associated with higher likelihood of urgency and urgency incontinence (aOR per -1 SD, 1.35, 1.40; 95% CI, 1.04-1.74, 1.06-1.84, respectively). CONCLUSIONS: In the healthy community-dwelling elderly, gait speed was associated with OAB, including urgency and urgency incontinence. Our findings may provide a new framework for OAB management with respect to functional mobility.

The impact of organ dysfunctions on mortality in patients with severe sepsis: A multicenter prospective observational study.

PURPOSE: Disseminated intravascular coagulations (DIC), acute respiratory distress syndrome (ARDS), and acute kidney injury (AKI) are major organ dysfunctions that occur in patients with sepsis. This study aimed to elucidate the impact of these organ dysfunctions on mortality in patients with severe sepsis. MATERIAL AND METHODS: A prospective observational study was performed in 10 ICUs to obtain data from patients with severe sepsis. Multivariate analyses to examine in-hospital mortality were performed. RESULTS: Data of 573 patients were analyzed. In-hospital mortality rate was 19.4% (111/573). The incidences of DIC, ARDS, and AKI were 58.4%, 18.7%, and 41.7%, while the associated mortality rates were 28.9%, 36.4%, and 31.8%, respectively. In multiple regression model, DIC (odds ratio 2.71, 95% confidence interval [CI] 1.45-5.27) and AKI stage 3 (odds ratio 1.98, 95% CI 1.07-3.63) were significantly associated with higher in-hospital all-cause mortality. DIC (hazard ratio 2.58, 95% CI 1.53-4.55) and AKI stage 3 (hazard ratio 1.73, 95% CI 1.07-2.80) were also significantly associated with longer survival durations. However, severe ARDS was not associated with these outcomes. CONCLUSIONS: DIC and AKI are frequent complications in patients with severe sepsis. In this study, DIC, and AKI stage 3 were independent risk factors of in-hospital mortality.

Presence of periaortic gas in Clostridium septicum-infected aortic aneurysm aids in early diagnosis: a case report and systematic review of the literature.

BACKGROUND: Clostridium septicum-infected aortic aneurysm is a fatal and rare disease. We present a fatal case of C. septicum-infected aortic aneurysm and a pertinent literature review with treatment suggestions for reducing mortality rates. CASE PRESENTATION: A 58-year-old Japanese man with an unremarkable medical history presented with a 3-day history of mild weakness in both legs, and experienced paraplegia and paresthesia a day before admission. Upon recognition of signs of an abdominal aortic aneurysm and paraplegia, we suspected an occluded Adamkiewicz artery and performed a contrast-enhanced computed tomography scan, which revealed an aortic aneurysm with periaortic gas extending from his chest to his abdomen and both kidneys. Antibiotics were initiated followed by emergency surgery for source control of the infection. However, owing to his poor condition and septic shock, aortic repair was not possible. We performed bilateral nephrectomy as a possible source control, after which we initiated mechanical ventilation, continuous hemodialysis, and hemoperfusion. A culture of the samples taken from the infected region and four consecutive blood cultures yielded C. septicum. His condition gradually improved postoperatively; however, on postoperative day 10, massive hemorrhage due to aortic rupture resulted in his death. CONCLUSIONS: In this patient, C. septicum was thought to have entered his blood through a gastrointestinal tumor, infected the aorta, and spread to his kidneys. However, we were uncertain whether there was an associated malignancy. A literature review of C. septicum-related aneurysms revealed the following: 6-month mortality, 79.5%; periaortic gas present in 92.6% of cases; no standard operative procedure and no guidelines for antimicrobial administration established; and C. septicum was associated with cancer in 82.5% of cases. Thus, we advocate for early diagnosis via the identification of periaortic gas, as an aortic aneurysm progresses rapidly. To reduce the risk of reinfection as well as infection of other sites, there is the need for concurrent surgical management of the aneurysm and any associated malignancy. We recommend debridement of the infectious focus and in situ vascular graft with omental coverage. Postoperatively, orally administered antibiotics must be continued indefinitely (chronic suppression therapy). We believe that these treatments will decrease mortality due to C. septicum-infected aortic aneurysms.

Low-dose immunoglobulin G is not associated with mortality in patients with sepsis and septic shock.

BACKGROUND: The administration of low-dose intravenous immunoglobulin G (IVIgG) (5 g/day for 3 days; approximate total 0.3 g/kg) is widely used as an adjunctive treatment for patients with sepsis in Japan, but its efficacy in the reduction of mortality has not been evaluated. We investigated whether the administration of low-dose IVIgG is associated with clinically important outcomes including intensive care unit (ICU) and in-hospital mortality. METHODS: This is a post-hoc subgroup analysis of data from a retrospective cohort study, the Japan Septic Disseminated Intravascular Coagulation (JSEPTIC DIC) study. The JSEPTIC DIC study was conducted in 42 ICUs in 40 institutions throughout Japan, and it investigated associations between sepsis-related coagulopathy, anticoagulation therapies, and clinical outcomes of 3195 adult patients with sepsis and septic shock admitted to ICUs from January 2011 through December 2013. To investigate associations between low-dose IVIgG administration and mortalities, propensity score-based matching analysis was used. RESULTS: IVIgG was administered to 960 patients (30.8%). Patients who received IVIgG were more severely ill than those who did not (Acute Physiology and Chronic Health Evaluation (APACHE) II score 24.2 ± 8.8 vs 22.6 ± 8.7, p < 0.001). They had higher ICU mortality (22.8% vs 17.4%, p < 0.001), but similar in-hospital mortality (34.4% vs 31.0%, p = 0.066). In propensity score-matched analysis, 653 pairs were created. Both ICU mortality and in-hospital mortality were similar between the two groups (21.0% vs 18.1%, p = 0.185, and 32.9% vs 28.6%, p = 0.093, respectively) using generalized estimating equations fitted with logistic regression models adjusted for other therapeutic interventions. The administration of IVIgG was not associated with ICU or in-hospital mortality (odds ratio (OR) 0.883; 95% confidence interval (CI) 0.655-1.192, p = 0.417, and OR 0.957, 95% CI, 0.724-1.265, p = 0.758, respectively). CONCLUSIONS: In this analysis of a large cohort of patients with sepsis and septic shock, the administration of low-dose IVIgG as an adjunctive therapy was not associated with a decrease in ICU or in-hospital mortality. TRIAL REGISTRATION: University Hospital Medical Information Network Individual Clinical Trials Registry, UMIN-CTR000012543 . Registered on 10 December 2013.

Antithrombin Supplementation and Mortality in Sepsis-Induced Disseminated Intravascular Coagulation: A Multicenter Retrospective Observational Study.

Supplemental doses of antithrombin (AT) are widely used to treat sepsis-induced disseminated intravascular coagulation (DIC) in Japan. However, evidence on the benefits of AT supplementation for DIC is insufficient. This multicenter retrospective observational study aimed to clarify the effect of AT supplementation on sepsis-induced DIC using propensity score analyses. Data from 3,195 consecutive adult patients admitted to 42 intensive care units for severe sepsis treatment were retrospectively analyzed; 1,784 patients were diagnosed with DIC (n = 715, AT group; n = 1,069, control group). Inverse probability of treatment-weighted propensity score analysis indicated a statistically significant association between AT supplementation and lower in-hospital all-cause mortality (n = 1,784, odds ratio [95% confidence intervals]: 0.748 [0.572-0.978], P = 0.034). However, quintile-stratified propensity score analysis (n = 1,784, odds ratio: 0.823 [0.646-1.050], P = 0.117) and propensity score matching analysis (461 matching pairs, odds ratio: 0.855 [0.649-1.125], P = 0.263) did not show this association. In the early days after intensive care unit admission, the survival rate was statistically higher in the propensity score-matched AT group than in the propensity score-matched control group (P = 0.007). In DIC patients without concomitant heparin administration, similar results were observed. In conclusion, AT supplementation may be associated with reduced in-hospital all-cause mortality in patients with sepsis-induced DIC. However, the statistical robustness of this connection was not strong. In addition, although the number of transfusions needed in patients with AT supplementation increased, severe bleeding complications did not.

Characteristics, treatments, and outcomes of severe sepsis of 3195 ICU-treated adult patients throughout Japan during 2011-2013.

Severe sepsis is a major concern in the intensive care unit (ICU), although there is very little epidemiological information regarding severe sepsis in Japan. This study evaluated 3195 patients with severe sepsis in 42 ICUs throughout Japan. The patients with severe sepsis had a mean age of 70 ± 15 years and a mean Acute Physiology and Chronic Health Evaluation II score of 23 ± 9. The estimated survival rates at 28 and 90 days after ICU admission were 73.6 and 56.3 %, respectively.