Clinical Features and Outcomes of Shoshin Beriberi.

Shoshin beriberi is a fulminant form of wet beriberi, but there are no large-scale studies detailing the clinical features of this disease. We investigated the clinical features and outcomes of Shoshin beriberi using data from a nationwide database in Japan.Using the Diagnosis Procedure Combination database, we identified patients with Shoshin beriberi between July 2010 and March 2021. We retrospectively investigated the characteristics, comorbidities, treatment, and in-hospital mortality of patients with Shoshin beriberi. The chi-square test or Fisher's exact test was used for categorical variables, and the Mann-Whitney U-test was used for continuous variables.We identified 62 patients with Shoshin beriberi. The median (interquartile range) age was 63 (48-69) years. Furthermore, 54 patients were male (87%). The most common comorbidity was alcohol-related disorder (34%). The median (interquartile range) length of hospital and intensive care unit stays were 17 (range, 10-35) and 5 (range, 1-9) days, respectively. The proportion of patients who received venoarterial extracorporeal membrane oxygenation, intra-aortic balloon pump, continuous renal replacement therapy, and mechanical ventilation was 11, 5, 29, and 63%, respectively. Among the patients with Shoshin beriberi, 53% received 2 or more catecholamines or inotropes. The in-hospital mortality was 23%. Impaired consciousness at admission was significantly related to in-hospital death (P < 0.001).The present study is the first and largest to describe the clinical features of patients with Shoshin beriberi using a nationwide database. Impaired consciousness at admission was significantly associated with in-hospital death.

Spinal epidural hematoma and abscess after neuraxial anesthesia: a historical cohort study using the Japanese Diagnosis Procedure Combination database.

BACKGROUND: Spinal epidural hematoma and abscess are rare complications of neuraxial anesthesia but can cause severe neurologic deficits. The incidence of these complications vary widely in existing studies and the risk factors remain uncertain. We estimated the incidence of these complications and explored associations using a national inpatient database in Japan. METHODS: Using Japanese Diagnosis Procedure Combination data on surgical inpatients who underwent neuraxial anesthesia from July 2010 to March 2017, we identified patients with spinal epidural hematoma and/or abscess. We investigated age, sex, Charlson comorbidity index, antithrombotic therapy, type of surgery, admission, and hospital for association with these complications. The incidences of spinal epidural hematoma and abscess were estimated separately, and a nested case-control study was performed to examine factors associated with these complications. RESULTS: We identified 139 patients with spinal epidural hematoma and/or abscess among 3,833,620 surgical patients undergoing neuraxial anesthesia. The incidences of spinal epidural hematoma and abscess were 27 (95% confidence interval [CI], 22 to 32) and 10 (7 to 13) per one million patients, respectively. Spinal anesthesia was associated with significantly fewer complications compared with epidural or combined spinal epidural anesthesia (odds ratio, 0.15; 95% CI, 0.08 to 0.32). Antiplatelet agent (odds ratio, 0.49; 95% CI, 0.06 to 3.91) and anticoagulants (odds ratio, 1.65; 95% CI, 0.95 to 2.85) were not significantly associated with these complications. CONCLUSIONS: This analysis identified the incidences of spinal epidural hematoma and/or abscess after neuraxial anesthesia. Additional large-scale studies are warranted to examine the incidences and factors associated with these complications.

RéSUMé: CONTEXTE: Les hématomes et abcès périduraux sont des complications rares de l'anesthésie neuraxiale qui peuvent toutefois provoquer des atteintes neurologiques graves. L'incidence de ces complications est très variable dans les études existantes et les facteurs de risque demeurent incertains. Nous avons estimé l'incidence de ces complications et exploré les associations en analysant une base de données nationale des patients hospitalisés au Japon. MéTHODE: En nous fondant sur la base de données japonaise Diagnosis Procedure Combination (DPC ­ un système de paiement des soins de santé uniformisé) de juillet 2010 et mars 2017, nous avons identifié les patients chirurgicaux hospitalisés ayant reçu une anesthésie neuraxiale et ayant souffert d'un hématome et/ou d'un abcès péridural. Nous avons examiné l'âge, le sexe, l'indice de comorbidité de Charlson, le traitement antithrombotique, le type de chirurgie, l'admission et l'établissement pour déterminer si ces facteurs étaient associés à ces complications. Les incidences d'hématomes et d'abcès périduraux rachidiens ont été séparément estimées, et une étude cas témoins imbriquée a été réalisée pour examiner les facteurs associés à ces complications. RéSULTATS: Nous avons identifié 139 patients ayant souffert d'un hématome et/ou d'un abcès péridural parmi les 3 833 620 patients chirurgicaux ayant reçu une anesthésie neuraxiale. Les incidences d'hématome et d'abcès périduraux rachidiens étaient de 27 (intervalle de confiance [IC] 95 %, 22 à 32) et 10 (7 à 13) par million de patients, respectivement. La rachianesthésie était associée à un nombre significativement plus faible de complications comparativement à une anesthésie péridurale ou péridurale rachidienne combinée (rapport de cotes, 0,15; IC 95 %, 0,08 à 0,32). Aucune association significative n'a été observée entre les agents antiplaquettaires (rapport de cotes, 0,49; IC 95 %, 0,06 à 3,91) ou les anticoagulants (rapport de cotes, 1,65; IC 95 %, 0,95 à 2,85) et ces complications. CONCLUSION: Cette analyse a identifié les incidences d'hématome et/ou d'abcès péridural après une anesthésie neuraxiale. Des études supplémentaires de grande envergure sont nécessaires pour examiner les incidences et les facteurs associés à ces complications.

Nafamostat mesylate-induced hyperkalemia in critically ill patients with COVID-19: Four case reports.

BACKGROUND: Nafamostat mesylate (NM) may prove to be one of the key drugs effective against coronavirus disease 2019 (COVID-19) because of its anti-viral properties and the potential to manage coagulopathy. However, NM tends to increase serum potassium levels. CASE SUMMARY: We observed hyperkalemia immediately after NM administration (200 mg/d) in four consecutive patients who were admitted to the Kanazawa University Hospital with severe COVID-19 pneumonia. Urinary potassium excretion decreased after NM administration in three patients who underwent urinalysis. CONCLUSION: NM is likely to produce hyperkalemia in patients with COVID-19. Therefore, it is necessary to monitor serum potassium values closely after NM initiation in COVID-19 patients who need respiratory support.

Impact of glucocorticoid supplementation on reducing perioperative complications in patients on long-term glucocorticoid medication: A propensity score analysis using a nationwide inpatient database.

BACKGROUND: Perioperative glucocorticoid supplementation has been suggested as a potentially effective precaution against perioperative adrenal crisis in patients on long-term glucocorticoid medication. METHODS: This retrospective cohort study used a national inpatient database in Japan. We included patients who underwent general surgery and those who received long-term glucocorticoid medication before surgery. A one-to-one propensity score-matched analysis was performed to compare patients who received 100 mg hydrocortisone during surgery with those who received no supplementation. The primary outcome was use of vasopressor agents on the day of surgery. The secondary outcomes included bleeding, perioperative infection, wound dehiscence, postoperative length of stay, and in-hospital mortality. RESULTS: Among the 807 propensity score-matched pairs, there was no significant difference in use of vasopressor agents between patients with and without glucocorticoid supplementation (24.5% vs. 21.9%; P = 0.22) and no significant differences in any secondary outcomes. CONCLUSIONS: Perioperative glucocorticoid supplementation was not associated with decreased morbidity or mortality.

Effect of Sugammadex on Postoperative Myasthenic Crisis in Myasthenia Gravis Patients: Propensity Score Analysis of a Japanese Nationwide Database.

BACKGROUND: In myasthenia gravis (MG) patients, postoperative myasthenic crisis, and residual neuromuscular blocking agent (NMBA) can cause respiratory failure that requires mechanical ventilation. However, it remains unclear whether the use of sugammadex for NMBA reversal reduces postoperative myasthenic crisis in MG patients undergoing surgery. We analyzed the association between use of sugammadex and postoperative myasthenic crisis in patients with MG using a national inpatient database. METHODS: Adult patients with MG who received thymectomy under general anesthesia were identified in the Japanese Diagnosis Procedure Combination database from July 1, 2010 to March 31, 2016. Patients who received sugammadex (sugammadex group) were compared with those who did not receive sugammadex (control group). The primary outcome was postoperative myasthenic crisis, and the secondary outcomes were postoperative pneumonia, tracheostomy, 28-day mortality, total hospitalization costs, and length of stay after surgery. Propensity scores were estimated by logistic regression based on the following variables: age; sex; body mass index (BMI); smoking index; history of cancer; Charlson comorbidity index (CCI); type of thymectomy; time from hospital admission to surgery; use of plasma exchange, immunosuppressants, corticosteroids, anticholinesterase, and oral benzodiazepine before surgery; type of hospital; and treatment year. The outcomes were compared using stabilized inverse probability of treatment weighting (IPTW) analyses to obtain good between-group balance. RESULTS: Of 795 patients identified, 506 patients received sugammadex and 289 patients did not. After stabilized IPTW, the sugammadex group was associated with a decrease in postoperative myasthenic crisis (22/507 [4.3%] vs 25/288 [8.7%]; odds ratio [OR], 0.48; 95% confidence interval [CI], 0.25-0.91), but not associated with a decrease in postoperative pneumonia (5/507 [1.0%] vs 7/288 [2.4%]; OR, 0.44; 95% CI, 0.17-1.14) or tracheostomy (7/507 [1.4%] vs 10/288 [3.5%]; OR, 0.38; 95% CI, 0.12-1.22) compared with the control group. The sugammadex group had significantly lower median (interquartile range) total hospitalization costs ($13,186 [$11,250-$16,988] vs $14,119 [$11,713-$20,207]; P < .001) and median length of stay after surgery (10 [8-15] vs 11 [8-18] days; P < .001), compared with the control group. CONCLUSIONS: In this retrospective observational study, sugammadex was associated with reductions in postoperative myasthenic crisis and total hospitalization costs in adult patients with MG who received thymectomy. Given the present findings, sugammadex should be routinely administered for MG patients undergoing thymectomy.

Continuous Neuromuscular Blockade and Mortality in Subjects With Exacerbation of Idiopathic Interstitial Pneumonias.

BACKGROUND: Exacerbation of idiopathic interstitial pneumonias (IIPs) requiring mechanical ventilation is associated with high mortality. However, evidence for the optimal management strategy in patients on mechanical ventilation for exacerbation of IIPs is scarce. This study aimed to evaluate the association between continuous rocuronium infusion and in-hospital mortality in patients with exacerbation of IIPs requiring mechanical ventilation. METHODS: The effect of continuous rocuronium infusion was retrospectively analyzed using data in the Japanese Diagnosis Procedure Combination in-patient database from July 2010 to March 2016. We compared 28-d mortality between the continuous rocuronium infusion group (intravenous doses of ≥ 150 mg/d) and the control group using 1:4 propensity score matching. RESULTS: We enrolled 4,925 subjects. Propensity score matching yielded 66 subjects in the rocuronium group and 264 subjects in the control group. There was no significant difference in 28-d mortality (rocuronium vs control, 52% vs 44%, P = .31) or in-hospital mortality (68% vs 61%, P = .28) between the 2 groups. CONCLUSIONS: Continuous rocuronium infusion was not significantly associated with decreased mortality in patients with exacerbation of IIPs requiring mechanical ventilation.

Mortality and detailed characteristics of pre-ICU qSOFA-negative patients with suspected sepsis: an observational study.

BACKGROUND: Recent studies have suggested that quick Sequential Organ Failure Assessment (qSOFA) scores have limited utility in early prognostication in high-mortality populations. The purpose of this study was to investigate the association between pre-ICU qSOFA scores and in-hospital mortality among patients admitted to the ICU with suspected sepsis. This study also aimed to describe detailed clinical characteristics of qSOFA-negative (< 2) patients. METHODS: This single center, observational study, conducted in a Japanese tertiary care teaching hospital between May 2012 and June 2016, enrolled all consecutive adult patients admitted to the ICU with suspected sepsis. We assessed pre-ICU qSOFA scores with the most abnormal vital signs during the 24-h period before ICU admission. The primary outcome was in-hospital mortality censored at 90 days. We analyzed the association between pre-ICU qSOFA scores and in-hospital mortality. RESULTS: Among 185 ICU patients with suspected sepsis, 14.1% (26/185) of patients remained qSOFA-negative at the time of ICU admission and 29.2% (54/185) of patients died while in hospital. In-hospital mortality was similar between the groups (qSOFA-positive [≥ 2]: 30.2% [48/159] vs qSOFA-negative: 23.1% [6/26], p = 0.642). The Cox proportional hazard regression model revealed that being qSOFA-positive was not significantly associated with in-hospital mortality (adjusted hazard ratio 1.35, 95% confidence interval 0.56-3.22, p = 0.506). Bloodstream infection, immunosuppression, and hematologic malignancy were observed more frequently in qSOFA-negative patients. CONCLUSIONS: Among ICU patients with suspected sepsis, we could not find a strong association between pre-ICU qSOFA scores and in-hospital mortality. Our study suggested high mortality and bacterial diversity in pre-ICU qSOFA-negative patients.

Interruption of enteral nutrition in the intensive care unit: a single-center survey.

BACKGROUND: Interruption of enteral nutrition (EN) in the intensive care unit (ICU) occurs frequently for various reasons including feeding intolerance and the conduct of diagnostic and therapeutic procedures. However, few studies have investigated the details of EN interruption practices including reasons for and duration of interruptions. There is no standard protocol to minimize EN interruptions. METHODS: This is a retrospective review of 100 patients in the ICU staying more than 72 h and receiving EN in a 12-bed, medical/surgical ICU in a tertiary care center in 2013. Data collected include total time designated for EN; the number of EN interruption episodes; reason for each interruption categorized as diagnostic study, therapeutic intervention, or gastrointestinal (GI) event, and their individual subcategories; duration of each interruption; and the presence of written orders for interruptions. RESULTS: One hundred patients staying in the ICU for at least 72 h and receiving EN were included. There were 567 episodes of EN interruption over a median ICU length of stay of 17.1 (interquartile range 8.0-22.0) days. There were a median of three EN interruption episodes per patient. EN interruption was performed for undetermined reasons (166 episodes, 29%), airway manipulation (103 episodes, 18%), GI events (78 episodes, 14%), and intermittent dialysis (71 episodes, 13%). Median duration of EN interruption in all patients was 5.5 (3.0-10.0) h. The cumulative interruption time corresponds to 19% of the total time designated for EN. Duration of EN interruption varied according to reason, including airway manipulation (9.0 [5.0-21.0] h), tracheostomy (9.5 [7.5-14.0] h), and GI events (6.5 [3.0-14.0] h). The average calorie deficits due to interruptions were 11.5% of daily target calories. Only 60 episodes (12%) had clear written orders for interruption. CONCLUSIONS: Based on this single-center retrospective chart review, interruption of EN in the ICU is frequent, reasons for and duration of interruption varied, and airway procedures are associated with a relatively longer duration of interruption. Documentation and orders were frequently missing. These results warrant development of a protocol for EN interruption.

Long-Term Survival in Patients With Acute Kidney Injury After Acute Type A Aortic Dissection Repair.

BACKGROUND: Although acute kidney injury (AKI) is known as a serious complication after operation for acute type A aortic dissection (AAAD), the long-term impact of AKI remains unclear. The aim of the present study is to investigate the long-term survival in patients with AKI after operation for AAAD. METHODS: This study included 403 patients who underwent operation for AAAD from 1990 to 2011 at Jichi Medical University, Saitama Medical Center. Postoperative AKI was identified according to the Kidney Disease Improving Global Outcomes criteria. Kaplan-Meier survival analysis and Cox proportional hazards regression were modeled to analyze the association between the AKI stage and postoperative long-term survival. RESULTS: Of 403 patients, 181 (44.9%) experienced postoperative AKI. Kaplan-Meier estimates for long-term survival were significantly different among patients without AKI and patients with stage 1, 2, and 3 AKI (p < 0.001). Hazard ratios of long-term survival for patients with stages 1, 2, and 3 AKI compared with patients without AKI were 1.38 (95% confidence interval [CI]: 0.84 to 2.26), 1.82 (95% CI: 0.95 to 3.51), and 3.79 (95% CI: 1.95 to 7.37), respectively. More patients with AKI died because of cardiovascular disease after discharge than patients without AKI (1.8% versus 6.0%, p = 0.03). CONCLUSIONS: Stage 3 AKI is significantly associated with lower long-term survival after operation for AAAD. Patient follow-up after discharge that focuses on cardiovascular issues may benefit patients who survive AKI after AAAD operation.

Lower heart rate in the early postoperative period does not correlate with long-term outcomes after repair of type A acute aortic dissection.

Little evidence exists regarding the need for a reduction in postoperative heart rate after repair of type A acute aortic dissection. This single-center retrospective study was conducted to determine if lower heart rate during the early postoperative phase is associated with improved long-term outcomes after surgery for patients with type A acute aortic dissection. We reviewed 434 patients who underwent aortic repair between 1990 and 2011. Based on the average heart rate on postoperative days 1, 3, 5, and 7, 434 patients were divided into four groups, less than 70, 70-79, 80-89, and greater than 90 beats per minute. The mean age was 63.3 ± 12.1 years. During a median follow-up of 52 months (range 16-102), 10-year survival in all groups was 67%, and the 10-year aortic event-free rate was 79%. The probability of survival and being aortic event-free using Kaplan-Meier estimates reveal that there is no significant difference when stratified by heart rate. Cox proportional regression analysis for 10-year mortality shows that significant predictors of mortality are age [Hazard Ratio (HR) 1.04; 95% confidence interval (CI) 1.07-1.06; p = 0.001] and perioperative stroke (HR 2.30; 95% CI 1.18-4.50; p = 0.024). Neither stratified heart rate around the time of surgery nor beta-blocker use at the time of discharge was significant. There is no association between stratified heart rate in the perioperative period with long-term outcomes after repair of type A acute aortic dissection. These findings need clarification with further clinical trials.

[Successful tracheal intubation using the GlideScope AVL in a pediatric patient with Pierre Robin syndrome].

We report a successful use of GlideScope AVL in a pediatric patient with Pierre Robin syndrome. A 36-day-old boy weighing 2.8 kg with Pierre Robin syndrome presented for tracheostomy after several weeks of trial airway management in prone position, who had failed to relieve his obstructive apnea. The Pentax-AWS videolaryngoscope equipped with the neonate Introck could not visualize his glottic opening. The GlideScope AVL single-use video laryngoscope equipping the #1 stat captured the view of the vocal cords. A tracheal tube (2.5 mm ID) with 90 degrees angled stylet, however, did not advance into the glottic opening, colliding with the anterior wall of the larynx and/or the laryngeal ventricle. Bending the tip of the stylet in a direction opposite to the inherent memory of the tube facilitated the placement of the tube into the trachea