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Background C1 inhibitor (C1-INH), which belongs to the superfamily of serine protease inhibitors, regulates the complement system and also the plasma kallikrein-kinin, fibrinolytic, and coagulation systems. The biologic activities of C1-INH can be divided into the regulation of vascular permeability and anti-inflammatory functions. The objective of this study was to clarify the serial change of C1-INH in patients with sepsis and evaluate the relationship with the shock severity. Methods This was a single-center, prospective, observational study. We serially examined C1-INH activity values (normal range 70–130%) in patients with sepsis admitted into the intensive care unit of the Trauma and Acute Critical Care Center at Osaka University Hospital (Osaka, Japan) during the period between January 2014 and August 2015. We defined “refractory shock” as septic shock unresponsive to conventional therapy such as adequate fluid resuscitation and vasopressor therapy to maintain hemodynamics. Results Serial changes of C1-INH were evaluated in 40 patients with sepsis (30 men, 10 women; 30 survivors, 10 non-survivors; mean age, 70 ± 13.5 years). We divided the patients into three groups: non-shock group (n = 14), non-refractory shock group (n = 13), and refractory shock group (n = 13: 3 survivors, 10 non-survivors). In the non-shock group, C1-INH was 107.3 ± 26.5% on admission and 104.2 ± 22.3% on day 1, and it increased thereafter to 128.1 ± 26.4% on day 3, 138.3 ± 21.2% on day 7, and 140.3 ± 12.5% on day 14 (p

Methicillin-resistant Staphylococcus aureus (MRSA) is one of the most important pathogens that cause nosocomial infections. However, microbiological culture techniques take a few days to yield results; therefore, a simple, cost-effective, and rapid detection system is required for screening for MRSA and related bacteria: Methicillin- resistant Staphylococcus epidermidis (MRSE) carriers during the hospital admissions process. In this study, we described the simplified method using by one-time use and screen-printed carbon electrodes, relied upon current quantification of Hoechst dyes which bound with DNA amplified via polymerase chain reaction (PCR) targeted for MRSA mecA gene. Amount of DNA-bound Hoechst molecules were measured by the hand-held potentiostat within two minutes. We found that the peak of a Hoechst-mediated current depended upon the number of MRSA cells, and successfully distinguished between carriers and a non-carrier based on nasal swabs from the patients. This method required only 10 µL for application, and the results could be obtained within total 60 min from sample collection when a minimum of 1 × 103 MRSA cells was present. These results suggested that this minimized technique has the potential to become a useful system of active surveillance for MRSA/MRSE carriers.

Key Clinical Message A number of complications can occur following both surgical tracheostomy (ST) and percutaneous tracheostomy (PT). A flexible new tracheostomy insertion technique with the advantages of both ST and PT is proposed to reduce these complications. Our blunt puncture and dilation technique (BPAD tracheostomy) appears to be technically safe and feasible to perform.

This study aimed to investigate the incidence, patient characteristics, and outcomes of out-of-hospital cardiac arrest (OHCA) occurring while in a motor vehicle in Osaka City, Japan (with a population of 2.6 million), from 2009 to 2015. The OHCA data used in this study were obtained from the population-based Utstein-style registry in Osaka City. Patients who had OHCA occurring while in a motor vehicle were included. The primary end point was 1-month survival with favorable neurologic outcome after OHCA. During the study period, 18,458 OHCAs were observed, and 264 of them (1.4%) occurred while on or in a motor vehicle (drivers, n = 179; nondrivers, n = 85). The overall incidence rate of OHCAs occurring while in a motor vehicle was 14.0 per million population per year (drivers, 9.5; nondrivers, 4.5). In the drivers with OHCAs, 78 (43.6%) and 101 (56.4%) cases were of medical origin and traffic injuries, respectively. Approximately half of OHCAs with a medical origin in drivers presumably occurred while driving (46.2%, 36 of 78). The overall proportion of 1-month survival with favorable neurologic outcome after OHCA was 6.4% (17 of 264). In the drivers, the proportion of OHCAs with a medical origin and because of traffic injuries were 11.5% (9 of 78) and 2.0% (2 of 101) (p = 0.008), respectively. In conclusion, although OHCAs occurring while in a motor vehicle represented a small subset of the overall OHCA burden, a relatively large number of cardiac arrests with a medical origin occurred in drivers.

Purpose One of the pathophysiological processes in sepsis is endothelial dysfunction, which leads to disseminated intravascular coagulation (DIC). Syndecan-1 is a major structural component of the endothelium and plays a key role in endothelial function. The purpose of this study was to assess the value of syndecan-1 as a predictive marker for DIC in sepsis. Methods We performed a prospective observational study of patients with sepsis from February 2014 to July 2015. Serial change of hemostatic markers, anticoagulant and fibrinolytic markers (antithrombin, PAI-1), endothelial markers (syndecan-1, VCAM-1, E-selectin), and inflammatory markers (IL-1β, IL-6, IL-8, HMGB-1, histone-H3) were analyzed. Clinical data including APACHE II, SOFA, and DIC scores and 28-day mortality were also evaluated. Results During the study, 39 septic patients and 15 healthy controls were included. Syndecan-1 levels were significantly increased in the septic patients compared with the healthy controls. Of the septic patients, non-survivors had higher syndecan-1 levels than did the survivors on days 1, 2, and 4. Significant correlations on day 1 were found between syndecan-1 levels and APACHE II, SOFA, and DIC scores, hemostatic markers, IL-1β, IL-8, and PAI-1. Syndecan-1 levels on day 1 were also significantly higher in patients with than without DIC and had strong discriminative power for the prediction of both DIC development and subsequent mortality, with AUCs of 0.79 and 0.85, respectively. Conclusion Syndecan-1 levels were associated with not only the severity of illness and mortality but also DIC development in sepsis, suggesting that syndecan-1 could be a predictive marker of DIC.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is now a feasible and less invasive resuscitation procedure. This study aimed to compare the clinical course of trauma and non-trauma patients undergoing REBOA. Patient demographics, etiology, bleeding sites, hemodynamic response, length of critical care, and cause of death were recorded. Characteristics and outcomes were compared between non-trauma and trauma patients. Kaplan–Meier survival analysis was then conducted. Between August 2011 and December 2015, 142 (36 non-trauma; 106 trauma) cases were analyzed. Non-traumatic etiologies included gastrointestinal bleeding, obstetrics and gynecology-derived events, visceral aneurysm, abdominal aortic aneurysm, and post-abdominal surgery. The abdomen was a common bleeding site (69%), followed by the pelvis or extra-pelvic retroperitoneum. None of the non-trauma patients had multiple bleeding sites, whereas 45% of trauma patients did (P

Background Deep vein thrombosis (DVT) is a major complication in critical care. There are various methods of prophylaxis, but none of them fully prevent DVT, and each method has adverse effects. Electrical muscle stimulation (EMS) could be a new effective approach to prevent DVT in intensive care unit (ICU) patients. We hypothesized that EMS increases the venous flow of the lower limbs and has a prophylactic effect against the formation of DVT. Methods This study included 26 patients admitted to a single ICU. We enrolled patients who could not move themselves due to spinal cord injury, head injury, central nervous system abnormalities, and sedation for mechanical ventilation. The patients were randomly allocated to either the EMS group or the control group. Patients in the EMS group received 30-min sessions of EMS applied to the bilateral lower extremities on arbitrary days within 14 days after admission. The control patients received no EMS. The peak flow velocity and diameter of the popliteal vein (Pop.V) and common femoral vein (CFV) were measured by ultrasound and then the volumes of venous flow were calculated using a formula. Results There were no statistically significant differences in patient characteristics between the two groups except for the mortality rate. In the EMS group, the median and interquartile range (IQR, 25th–75th percentile) of velocities of the Pop.V and CFV were higher during EMS compared with at rest: 10.6 (8.0–14.8) vs 24.5 (15.1–37.8) cm/s and 17.0 (12.3–23.8) vs 24.3 (17.0–33.0) cm/s, respectively (p

Aim We aimed to create a system for monitoring of regional cerebral oxygen saturation (rSO2) in patients with prehospital cardiopulmonary arrest and clarify the changes in rSO2 during cardiopulmonary resuscitation. Methods We measured rSO2 in cardiopulmonary arrest patients who were transferred by the emergency response vehicle of Nagasaki University Hospital. We developed a portable rSO2 monitor (HAND ai TOS), which is small enough to carry during prehospital treatment. The sensor is attached to the forehead of the patient and monitors rSO2 continuously during treatment and transfer. Results No difficulties were experienced in monitoring rSO2 during patient treatment and transfer. Median time (interquartile range) from the emergency medical service call to emergency response vehicle arrival was 15.0 min (11.0–19.5 min). Median rSO2 on emergency response vehicle arrival at the scene was 46.3% (44.0–48.2%) (n = 9; median age, 74.0 years; four men, five women). Median rSO2 showed significant increase within 5 min after return of spontaneous circulation (n = 6, 46.6% versus 58.7%, P

Protein metabolism is important in healing wounds, supporting immune function, and maintaining lean body mass. Determination of adequate requirements of amino acids has not been thoroughly clarified in critically ill patients. The purpose of this study was to evaluate 23 plasma amino acids in patients with sepsis and determine prognostic factors.This study was a retrospective study. Plasma aminograms were measured in patients with sepsis. We evaluated minimum and maximum values of each amino acid and evaluated prognostic factors by multivariate logistic regression analysis and classification and regression tree (CART) analysis.The study comprised 77 patients. The median intensive care unit (ICU) stay was 30 days (interquartile range 19.5-55.5 days). Whole mortality rate was 39.0%. Maximum values of glutamine, glutamate, glycine, alanine, methionine, phenylalanine, and histidine and minimum values of glutamate, taurine, serine, isoleucine, leucine, tyrosine, ornithine, tryptophan, and arginine were significantly different between survivors and non-survivors (P0.05). Statistical analysis using CART analysis revealed the minimum value of glutamate and maximum value of methionine to be significant prognostic factors for mortality (P0.05).Plasma aminograms were significantly altered in patients with sepsis. Altered balance of aminograms was significantly associated with mortality in patients with sepsis requiring a long ICU stay.

Objective Neutrophils are able to form ‘neutrophil extracellular traps’ (NETs), which they use to trap and kill pathogens such as bacteria and fungi at the foci of infection. This observational study investigated the presence of NETs in the blood from critically ill patients and healthy volunteers. Methods Fluorescent triple-colour immunocytochemical analysis of blood smears collected from patients with systemic inflammatory response syndrome (SIRS; associated with various clinical conditions) who had been hospitalized in the intensive care unit, and healthy volunteers, was undertaken to identify NETs in the blood. Blood smears were stained for DNA, histone H1 and neutrophil elastase. Results NETs were identified in 10 of 21 (47.6%) blood samples from the study group compared with none of the blood samples from eight healthy volunteers. Conclusion These data suggest that fluorescent triple-colour immunocytochemical staining of NETs in the blood could be used to simplify the early identification of critically ill patients with SIRS. Larger studies are required to clarify the pathophysiological role of NETs in this specific patient population.

The mechanisms accounting for the development of tissue damage following traumatic brain injury (TBI) have been studied for several decades. A variety of mediators, such as vascular endothelial growth factor (VEGF) and matrix metalloproteinase-9 (MMP-9), which play a crucial role in edema formation after TBI, have been identified. We experienced a case of brain edema that progressed continuously at least until 13 days after head injury. The brain edema occurred around the hemorrhage from an intracerebral contusion. The evacuated hematoma was investigated based on the inference that the unexpected expansion of edema was induced by the mediators within the hematoma itself. A 64-year-old woman was admitted to our hospital following a traffic injury. Left brain contusion was revealed by head computed tomography (CT) on admission. Three hours later, formation of an intracerebral hematoma became evident. Serial CT examination revealed that brain edema had developed progressively till 13 days after the injury. A hematoma removal operation was performed on Day 13. The hematoma was centrifuged and the supernatant was analyzed for the expression of VEGF and MMP-9. The values of both (4400 pg/ml and 920 ng/ml, respectively) were extremely high compared with values reported previously in serum and cerebrospinal fluid collected from patients with intracranial infection or injury. This case suggested that the delayed exacerbation of edema following traumatic intracranial hemorrhage was possibly induced by secretory factors such as VEGF and MMP-9 released from within and around the hematoma.

Background In recent years, measurement of cerebral regional oxygen saturation (rSO2) has attracted attention during resuscitation. However, serial changes of cerebral rSO2 in pre-hospital settings are unclear. The objective of this study was to clarify serial changes in cerebral rSO2 of patients with out-of-hospital cardiac arrest (OHCA) in the pre-hospital setting. Methods We recently developed a portable rSO2 monitor that is small (170 × 100 × 50 mm in size and 600 g in weight) enough to carry in pre-hospital settings. The sensor is attached to the patient’s forehead by the ELT (Emergency Life-saving Technician), and it monitors rSO2 continuously. Results From June 2013 through August 2014, serial changes in cerebral rSO2 in seven patients were evaluated. According to the results of the serial changes in rSO2, four patterns of rSO2 change were found, as follows. Type 1: High rSO2 (around about 60 %) type (n = 1). Initial electrocardiogram was ventricular fibrillation and ROSC (return of spontaneous circulation) could be diagnosed in pre-hospital setting. Her outcome at discharge was Good Recovery (GR). Type 2: Low rSO2 (around about 45–50 %) type (n = 3). They did not get ROSC even once. Type 3: Gradually decreasing rSO2 type (n = 2): ROSC could be diagnosed in hospital, but not in pre-hospital setting. Their outcomes at discharge were not GR. Type 4: other type (n = 1). In this patient with ROSC when ELT started cerebral rSO2 measurement, cerebral rSO2 was 67.3 % at measurement start, it dropped gradually to 54.5 %, and then rose to 74.3 %. The cerebral oxygenation was impaired due to possible cardiac arrest again, and after that, ROSC led to the recovery of cerebral blood flow. Conclusion We could measure serial changes in cerebral rSO2 in seven patients with OHCA in the pre-hospital setting. Our data suggest that pre-hospital monitoring of cerebral rSO2 might lead to a new resuscitation strategy. Electronic supplementary material The online version of this article (doi:10.1186/s13104-016-2239-4) contains supplementary material, which is available to authorized users.

Katayama, Yusuke MD, PhD; Kitamura, Tetsuhisa MD, DrPHb; Hirose, Tomoya MD, PhDa,c; Kiguchi, Takeyuki MD, PhD; Matsuyama, Tasuku MD, PhDe; Sado, Junya PhDb; Kiyohara, Kosuke DrPH; Izawa, Junichi MD, DrPH; Tachino, Jotaro MD; Ebihara, Takeshi MD; Yoshiya, Kazuhisa MD, PhD; Nakagawa, Yuko MD, PhD; Shimazu, Takeshi MD, PhDa Delay of computed tomography is associated with poor outcome in patients with blunt traumatic aortic injury, Medicine: August 2018 - Volume 97 - Issue 35 - p e12112 doi: 10.1097/MD.0000000000012112, According to guidelines from the Eastern Association for the Surgery of Trauma, computed tomography (CT) with intravenous contrast is strongly recommended to diagnose clinically significant blunt traumatic aortic injury (BTAI). However, it remains unclear whether the timing of CT scanning is associated with the prognosis of BTAI patients. We extracted data on emergency patients who suffered a BTAI in the chest and/or the abdomen from 2004 to 2015 from the Japanese Trauma Data Bank, a nationwide trauma registry. The primary outcome was death in the emergency department (ED) and secondary outcome was discharge to death. In addition, we assessed the relationship between death in the ED and the timing of CT scanning by shock status in subgroup analysis. We divided these patients into the tertile groups of early (26minutes), middle (27- 40minutes), and late (≥41minutes) phases based on the time interval from hospital arrival to start of first CT scanning, and assessed death of BTAI patients in the ED by CT scanning time with the use of a multivariable logistic regression model. In total, 421 patients who suffered BTAI in the chest and/or the abdomen were eligible for our analysis. The proportion of patients dying at hospital admission was 7.7% (11/142) in the early group, 11.1% (15/135) in the middle group, and 17.6% (25/144) in the late group. In a multivariable logistic regression adjusted for confounding factors, the adjusted odds ratio (AOR) of death in the ED was 1.833 (95% confidence interval [CI]: 0.601-5.590, P=.287) in the middle group and 2.832 (95% CI: 1.007-7.960, P=.048) in the late group compared with the early group. Compared with the early group, the late group tended to have a higher rate of discharge to death (AOR: 1.438, 95% CI: 0.735-2.813). In the patients with shock, the AOR was 3.292 (95% CI: 0.495-21.902) in the middle group and 6.039 (95% CI: 0.990-36.837) in the late group compared with the early group. This study revealed that a longer time interval from hospital arrival to CT scanning was associated with higher mortality in the ED in patients with BTAI.

Background and purpose The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J-SSCG 2016), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in February 2017 and published in the Journal of JSICM, [2017; Volume 24 (supplement 2)] 10.3918/jsicm.24S0001 and Journal of Japanese Association for Acute Medicine [2017; Volume 28, (supplement 1)] http://onlinelibrary.wiley.com/doi/10.1002/jja2.2017.28.issue-S1/issuetoc. This abridged English edition of the J-SSCG 2016 was produced with permission from the Japanese Association of Acute Medicine and the Japanese Society for Intensive Care Medicine. Methods Members of the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine were selected and organized into 19 committee members and 52 working group members. The guidelines were prepared in accordance with the Medical Information Network Distribution Service (Minds) creation procedures. The Academic Guidelines Promotion Team was organized to oversee and provide academic support to the respective activities allocated to each Guideline Creation Team. To improve quality assurance and workflow transparency, a mutual peer review system was established, and discussions within each team were open to the public. Public comments were collected once after the initial formulation of a clinical question (CQ) and twice during the review of the final draft. Recommendations were determined to have been adopted after obtaining support from a two-thirds (> 66.6%) majority vote of each of the 19 committee members. Results A total of 87 CQs were selected among 19 clinical areas, including pediatric topics and several other important areas not covered in the first edition of the Japanese guidelines (J-SSCG 2012). The approval rate obtained through committee voting, in addition to ratings of the strengths of the recommendation, and its supporting evidence were also added to each recommendation statement. We conducted meta-analyses for 29 CQs. Thirty-seven CQs contained recommendations in the form of an expert consensus due to insufficient evidence. No recommendations were provided for five CQs. Conclusions Based on the evidence gathered, we were able to formulate Japanese-specific clinical practice guidelines that are tailored to the Japanese context in a highly transparent manner. These guidelines can easily be used not only by specialists, but also by non-specialists, general clinicians, nurses, pharmacists, clinical engineers, and other healthcare professionals. Electronic supplementary material The online version of this article (10.1186/s40560-017-0270-8) contains supplementary material, which is available to authorized users.

Pneumorachis rarely occurs after spreading from a contiguous site of infection or after a traumatic event. We describe an adult patient who developed sepsis and a renal abscess due to Citrobacter koseri, and computed tomographic imaging identified gas within the entire spinal canal as well as an iliopsoas abscess. This patient recovered from pneumorachis caused by disseminated infection.

Objective: We aimed to clarify the change in rSO2, blood pressure (BP) and arterial oxygen saturation (SpO2) in CPA patients who got return of spontaneous circulation (ROSC). Method: We measured rSO2 in CPA patients who were transferred to two tertiary emergency medical centers. On arrival, rSO2 sensor was attached to the forehead of patients, and monitored continuously during cardiopulmonary resuscitation. In the patients who got ROSC, we compared change in rSO2 and BP, SpO2, and evaluated the correlation between rSO2 and physiological parameters. Result: There were 79 CPA patients transferred to the tertiary emergency medical centers, and 38 patients got ROSC(Mean Age 74.8,M:F=25:13). rSO2 increased after ROSC, and showed the significance after 10 minutes after ROSC. Median rSO2 just after ROSC (ROSC 0) was 54.4% (47.2-59.5), and 66.0% (61.8-70.0) in 10 minutes after ROSC (ROSC 10) (Figure, p Conclusion: We clarified that there is a delay in rSO2 recovery compared to BP, SpO2 recovery after ROSC in CPA patients. It might be a therapeutic point to correct the delay in rSO2 recovery.

[Background] Recently, the patients with out-of-hospital cardiac arrest are increasing. It is very important to do chest compression continuously for the return of spontaneous circulation (ROSC). But we can not but stop chest compression during checking pulse every few minutes. We reported that Regional cerebral Oxygen Saturation (rSO2) value was not elevated by manual chest compression and mechanical chest compression increased a little rSO2 value on CPR without ROSC and rSO2 value became a good parameter of ROSC in single center study. [Purpose] The purpose of this study is to evaluate clinical utility of rSO2 value during CPR in multicenter study. [Method] Retrospectively, we considered the rSO2 value of the out-of -hospital cardiac arrest patients from December 2012 to December 2014 in multicenter. During CPR, rSO2 were recorded continuously from the forehead of the patients by TOS-OR (Japan). CPR for patients with OHCA was performed according to the JRC-guidelines 2010. [Result] 252 patients with OHCA were included in this study. The rSO2 value on arrival, during CPR and ROSC were 44.4±8.9%, 45.4±9.7%, 58.6±9.2%. In ROSC, with rSO2 cutoff value of 52.7%, the specificity and sensitivity were 80% and 79%, respectively. The negative predict value was 99.2%, respectively. It means little possible to ROSC, if the rSO2 value is less than 52.7%. So, it may be possible to reduce the frequency of checking pulse during CPR. [Conclusion] The monitoring of rSO2 value could reduce the frequency of checking pulse during CPR and do chest compression continuously.

Background Despite advances in therapeutic strategies and improved guidelines, morbidity and mortality rates for out-of-hospital cardiac arrest (OHCA) remain high. Especially, neurological prognosis is one of the most important problems even though brain protection therapy for patients with OHCA has improved greatly in recent years due to the development of emergency post-cardiac arrest interventions such as mild therapeutic hypothermia, early percutaneous coronary intervention, and extracorporeal cardiopulmonary resuscitation (CPR). Recently, cerebral regional oxygen saturation (rSO2) has received attention as a method for evaluation of cerebral oxygenation. We have reported that conventional chest compression did not improve the rSO2 of cardiac arrest patients if they did not achieve return of spontaneous circulation. It is, however, unclear whether a mechanical CPR device is helpful in improving rSO2. The purpose of this study was to evaluate the effects of load-distributing-band CPR (LDB-CPR) on rSO2. Methods In this prospective study, LDB-CPR was begun for OHCA with the AutoPulseTM device on patient arrival at hospital. During mechanical CPR, rSO2 values were recorded continuously from the forehead of the patients. CPR for patients with OHCA was performed according to the Japan Resuscitation Council Guidelines 2010 except for using the AutoPulseTM instead of manual chest compression. Results From December 2012 to December 2013, 34 patients (mean age, 75.6 ± 12.8 years) with OHCA were included in this study. Duration of time from recognition of cardiac collapse to arrival to hospital was 31.0 ± 11.4 min. Compared with the rSO2 value of 38.9 ± 0.7 % prior to starting LDB-CPR, rSO2 values at 4, 8 and 12 minutes increased significantly after initiation of LDB-CPR (44.0 ± 0.9 %, 45.2 ± 0.8 %, and 45.5 ± 0.8 %, respectively, p

Purpose Nutritional biochemical indexes are generally used as markers for critically ill patients. However, they are easily influenced by acute phase changes after injury and are difficult to use as common and practical biomarkers. The objective of this study was to determine the most valuable prognostic markers among 15 common laboratory tests in patients with sepsis. Methods We included all sepsis patients who stayed in the intensive care unit for more than 2 weeks. We evaluated 15 biochemistry indexes including serum albumin, total protein, C-reactive protein, cholinesterase, total cholesterol (T-Cho), triglyceride, sodium, potassium, blood urea nitrogen, creatinine, aspartate aminotransferase, alanine aminotransferase, lactate dehydrogenase, total bilirubin (T-Bil), and prothrombin time. The minimum and maximum values of these indexes during the first 14 days from admission were analyzed by classification and regression tree and multivariate logistic regression analyses. Results This study comprised 91 patients with sepsis. The primary split was the minimum value of serum T-Cho (T-Cho (Min)), and the cutoff value was 73.5 mg/dL by classification and regression tree analysis. The second split was the maximum value of T-Bil (T-Bil (Max)), and the cutoff value was 1.35 mg/dL. The rate of mortality was 63% (17/27) in the group with T-Cho (Min) less than 73.5 mg/dL and T-Bil (Max) greater than 1.35 mg/dL. Multivariate logistic regression revealed that T-Cho (Min) and T-Bil (Max) were the biomarkers most closely associated with prognosis. Conclusions Total cholesterol and T-Bil could be associated with prognosis in patients with sepsis.

Masafumi Seki,1,2,* Hiroki Takahashi,3,* Norihisa Yamamoto,1 Shigeto Hamaguchi,1 Masahiro Ojima,3 Tomoya Hirose,3 Kazuhisa Yoshiya,3 Hiroshi Ogura,3 Takeshi Shimazu,3 Kazunori Tomono11Division of Infection Control and Prevention, Osaka University Hospital, Suita, Osaka, Japan; 2Division of Infection Control and Prevention, Tohoku Pharmaceutical University Hospital, Sendai, Japan; 3Department of Traumatology and Acute Critical Medicine, Osaka University Hospital, Suita, Osaka, Japan*These authors contributed equally to this work Abstract: Conventional culture methods to detect methicillin-resistant Staphylococcus aureus (MRSA) take a few days, and their sensitivity and usefulness also need to be improved. In this study, active screening was performed using the polymerase chain reaction (PCR) for colonization with MRSA on admission and follow-up surveillance after admission to an emergency department between June 2012 and August 2012, and the backgrounds of PCR and/or culture-method-positive patients were compared. Among 95 patients, 15 (15.8%) patients were positive for MRSA on PCR and/or culture; 6.3% (6/95) of patients were positive on admission, and 9.5% (9/95) became positive during the stay after admission. The major primary diagnoses in MRSA-positive patients were trauma and cerebrovascular diseases. Nine (60%) of 15 patients were MRSA-positive on both PCR and culture, compared with three (20%) of 15 who were PCR-positive but culture-negative. The other three (20%) of 15 patients were PCR-negative but culture-positive. Furthermore, there was a tendency for younger age and shorter stay to be associated with PCR-positive but culture-negative results. These findings suggest that active surveillance with PCR may be highly sensitive and useful for the early diagnosis of MRSA colonization to prevent nosocomial transmission from the emergency department to the regular inpatient wards of the hospital. Keywords: active surveillance, length of stay, nosocomial transmission, BD GeneOhm MRSA assay, sensitivity, specificity&nbsp

Hiroki Takahashi,1,* Masafumi Seki,2,4,* Norihisa Yamamoto,2 Shigeto Hamaguchi,2 Masahiro Ojima,1 Tomoya Hirose,1 Kazuhisa Yoshiya,1 Masahiro Toyokawa,3 Isao Nishi,3 Hiroshi Ogura,1 Takeshi Shimazu,1 Kazunori Tomono21Department of Traumatology and Acute Critical Medicine, Osaka University Hospital, Suita, Osaka, Japan; 2Division of Infection Control and Prevention, Osaka University Hospital, Suita, Osaka, Japan; 3Laboratory for Clinical Investigation, Osaka University Hospital, Suita, Osaka, Japan; 4Division of Infection Control and Prevention, Tohoku Pharmaceutical University Hospital, Sendai, Japan *These authors contributed equally to this work Abstract: Surveillance is very important to prevent the nosocomial spread of methicillin-resistant Staphylococcus aureus (MRSA), and infection sources and routes have historically been identified using molecular and epidemiological genotyping with pulsed-field gel electrophoresis. However, phage-open reading frame typing (POT) has recently been developed. Here, we investigated whether POT would be useful to survey MRSA outbreaks and transmission. We therefore applied POT to 91 MRSA isolates detected in cultures from inpatients at our hospital between May and October 2014. Among the 91 isolates, 12 POT types comprising 38 isolated MRSA strains were considered as overlapping. Five of them were detected in different wards, whereas the remaining seven were found in the same ward, including the emergency department. Three of seven POT number 93-155-111 strains were detected in the surgical ward, and all of four POT number 93-157-61 strains were detected in the cardiosurgical ward. These data suggested that transmission of the MRSA strains with the same POT-types from the same wards was nosocomial, and that POT accurately and rapidly identified MRSA strains, which allowed effective control of infection and transmission. Keywords: MRSA, active surveillance, POT, nosocomial transmission&nbsp

ejd.2012.1870 Auteur(s) : Toshifumi Yamaoka1 yamaoka@derma.med.osaka-u.ac.jp, Hiroaki Azukizawa1, Atsushi Tanemura1, Hiroyuki Murota1, Tomoya Hirose2, Koichi Hayakawa2, Takeshi Shimazu2, Naoki Wada3, Eiichi Morii3, Ichiro Katayama1 1 Department of Dermatology, 2 Department of Traumatology and Acute Critical Medicine, 3 Department of Pathology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka 565-0871 Osaka, Japan Toxic epidermal necrolysis (TEN) is a condition of blistering and [...]

Hereditary angioedema (HAE) with deficiency of C1 inhibitor (C1-INH) is an autosomal-dominant disease characterized by recurrent episodes of potentially life-threatening angioedema. The objective is to study the incidence of HAE among patients who visit the emergency department. This was a 3-year prospective observational screening study involving 13 urban tertiary emergency centers in Osaka prefecture, Japan. Patients were included if they met the following criteria: unexplained edema of the body, upper airway obstruction accompanied by edema, anaphylaxis, acute abdomen with intestinal edema (including ileus and acute pancreatitis), or asthma attack. C1-INH activity and C4 level were measured at the time of emergency department admission during the period between July 2011 and June 2014. This study comprised 66 patients with a median age of 54.0 (IQR: 37.5–68.3) years. Three patients were newly diagnosed as having HAE, and 1 patient had already been diagnosed as having HAE. C1-INH activity levels of the patients with HAE were below the detection limit (

Neutrophil extracellular traps (NETs) are structures composed of DNA and granular proteins, which rapidly trap and kill pathogens. The formation of NETs has been detected during infection in animal experiments, but their role in humans is unclear. The purposes of this study were to quantitatively evaluate the production of NETs during acute respiratory infection and to study the relationship between the NET length and various inflammatory mediators. We examined bronchial aspirates collected from nine intubated patients in an intensive care unit. Samples were collected at the onset of acute respiratory infection (day 0) and on days 1, 3-5, and 6-8. The NET length was visualised by immunohistochemistry and quantified using computer tracing software. The NET length was measured and compared at each time point. The length differed significantly between time points (p

Background The 2010 Consensus on Science and Treatment Recommendations Statement recommended that short video/computer self-instruction courses, with minimal or no instructor coaching, combined with hands-on practice can be considered an effective alternative to instructor-led basic life support courses. The purpose of this study was to examine the effectiveness of a simplified cardiopulmonary resuscitation (CPR) training program for non-medical staff working at a university hospital. Methods Before and immediately after a 45-min CPR training program consisting of instruction on chest compression and automated external defibrillator (AED) use with a personal training manikin, CPR skills were automatically recorded and evaluated. Participants’ attitudes towards CPR were evaluated by a questionnaire survey. Results From September 2011 through March 2013, 161 participants attended the program. We evaluated chest compression technique in 109 of these participants. The number of chest compressions delivered after the program versus that before was significantly greater (110.8 ± 13.0/min vs 94.2 ± 27.4/min, p

Objective Although starvation is associated with high in-hospital mortality, its related cardiac complications are not sufficiently understood. The aim of this study was to determine the clinical course and pathogenesis of cardiac complications in malnourished patients. Methods We reviewed three cases of hypoglycemia and hypotriglyceridemia with cardiac complications in starvation. Results This report concerns three patients, respectively suffering from anorexia nervosa, esophageal carcinoma, and Parkinson's disease. Their ages ranged from 18 to 70 y, body mass index was 11.5 ± 1.5 kg/m 2 (mean ± SD), and the main symptom was coma. The average blood glucose level was 15.7 ± 7.8 mg/dL without any history of insulin use or diabetes mellitus. In all cases, hypoglycemia was refractory and repetitive so that continuous glucose administration was required to maintain euglycemia. Serum triglyceride and non-esterified fatty acid levels were also very low (7 ± 4 mg/dL and 10 ± 9.1 μEq/L, respectively). Levels of serum potassium, phosphate, and magnesium were almost normal at admission. The main cardiac complications included Takotsubo cardiomyopathy and cardiac arrest. All patients survived as a result of intensive treatment. Conclusions Repetitive severe hypoglycemia without known background causes should be viewed as an important sign. Once this occurs, the administration of a much higher caloric input than usual accompanied by intensive monitoring will be required to maintain appropriate glucose levels. The early identification of such patients seems to be essential to reduce the high risk for cardiac complications during starvation and refeeding.

Purpose: Disuse atrophy of the lower limbs of patients with consciousness disturbance has often been recognized as “an unavoidable consequence,” such that the mechanism was not investigated diligently. In thisstudy, weexamined the preventive effectsofelectrical musclestimulation (EMS)againstdisuseatrophy of the lower limbs in patients in coma after stroke or traumatic brain injury in the intensive care unit. MaterialsandMethods:We evaluated changes in cross-sectional area of lower limb muscles weekly with computed tomography in 6 control group patients and 9 EMS group patients. Electrical muscle stimulation was performed daily from day 7 after admission. We evaluated the anterior thigh muscle compartment, posterior thigh muscle compartment, anterior leg muscle compartment, and posterior leg muscle compartment. Results: Inthecontrolgroup,thedecreaseincross-sectionalareaprogressedinallcompartmentseveryweek (P b .0001). Cross-sectional areas of all compartments at day 14 were significantly decreased in the control group compared with those in the EMS group at day 7 (P b .001). We were able to limit the rate of muscle atrophy as measured in the cross-sectional areas to within 4% during the period of EMS (days 7-42) in 5 patients. The difference between the control and the EMS groups was statistically significant (P b .001). Conclusion: Electrical muscle stimulation is effective in the prevention of disuse muscle atrophy in patients with consciousness disorder.

No specific treatment exists for poisoning with most fat-soluble drugs. Intravenous lipid emulsion (ILE) may be effective therapy against such drugs, but effects of ILE treatment are unclear. A 24-year-old woman with depression seen sleeping in the morning was found comatose in the evening, and an emerging lifesaving technologies service was called. After emerging lifesaving technologies departure to hospital, she stopped breathing, became pulseless, and cardiopulmonary life support was started immediately. Electrocardiographic monitoring showed asystole during resuscitation even after arrival at hospital. Empty packaging sheets of 60-tablet chlorpromazine (CPZ) (50 mg/tablet) and 66-tablet mirtazapine (MZP) (15 mg/tablet) found at the scene suggested drug-related cardiopulmonary arrest. Along with conventional administration of adrenaline (total dose, 5 mg), 20% Intralipid 100 mLwas given intravenously 8 minutes after hospital arrival and readministered 27 minutes after hospital arrival because of continued asystole. Return of spontaneous circulation occurred 29 minutes after arrival (70 minutes after cardiac arrest). The patient recovered without any major complications and was transferred to another hospital for psychiatric treatment 70 days after admission. Concentrations of CPZ and MZP were still high when return of spontaneous circulation was achieved with ILE. This case suggested the possible benefit of ILE in treating life threatening cardiotoxicity from CPZ and MZP overdose.

Neutrophils work as the frontline of defense against infections and neutrophil extracellular traps (NETs) are one of the immune systems to suppress dissemination of infection by the netted chromatin decorated with antibacterial molecules. It was reported that NETs play an important role in various kinds of infections such as pneumonia. However, there is no report on NETs in patients of soft tissue infections. In this study, we evaluated NET production in pus and clarified the role of NETs as a host defense in patients of soft tissue infections.

Neutrophil extracellular traps (NETs) are fibrous structures that are produced extracellularly from activated neutrophil. They can trap and kill various pathogens, and their release is one of the first lines of immune system. Meanwhile, recently it was reported that NETs also exert adverse effects in inflammatory diseases. Acute respiratory distress syndrome (ARDS) and acute exacerbation of idiopathic pulmonary fibrosis is acute-onset respiratory failure. It is characterized by excessive neutrophil infiltration into the alveolus, and great amounts of neutrophil elastase are released. The purpose of this study is to evaluate whether NETs are produced in bronchial aspirate of patients with ARDS or acute exacerbation of idiopathic pulmonary fibrosis, and to identify correlations with the respiratory function.

Neutrophil extracellular traps (NETs), a newly identified immune mechanism, are induced by inflammatory stimuli. Modification by citrullination of histone H3 is thought to be involved in the in vitro formation of NETs. The purposes of this study were to evaluate whether NETs and citrullinated histone H3 (Cit-H3) are present in the bloodstream of critically ill patients and to identify correlations with clinical and biological parameters. Blood samples were collected from intubated patients at the time of ICU admission from April to June 2011. To identify NETs, DNA and histone H3 were visualized simultaneously by immunofluorescence in blood smears. Cit-H3 was detected using a specific antibody. We assessed relationships of the presence of NETs and Cit-H3 with the existence of bacteria in tracheal aspirate, SIRS, diagnosis, WBC count, and concentrations of IL-8, TNF-a, cf-DNA, lactate, and HMGB1. Forty-nine patients were included. The median of age was 66.0 (IQR: 52.5-76.0) years. The diagnoses included trauma (7, 14.3%), infection (14, 28.6%), resuscitation from cardiopulmonary arrest (8, 16.3%), acute poisoning (4, 8.1%), heart disease (4, 8.1%), brain stroke (8, 16.3%), heat stroke (2, 4.1%), and others (2, 4.1%). We identified NETs in 5 patients and Cit-H3 in 11 patients. NETs and/or Cit-H3 were observed more frequently in "the presence of bacteria in tracheal aspirate" group (11/22, 50.0%) than in "the absence of bacteria in tracheal aspirate" group (4/27, 14.8%) (p, PLoS ONE, 9(11), e111755; 2014

Introduction Cross-talk between the coagulation system and inflammatory reactions during sepsis causes organ damage followed by multiple organ dysfunction syndrome or even death. Therefore, anticoagulant therapies have been expected to be beneficial in the treatment of severe sepsis. Recombinant human soluble thrombomodulin (rhTM) binds to thrombin to inactivate coagulation, and the thrombin-rhTM complex activates protein C to produce activated protein C. The purpose of this study was to examine the efficacy of rhTM for treating patients with sepsis-induced disseminated intravascular coagulation (DIC). Methods This study comprised 65 patients with sepsis-induced DIC who required ventilatory management. All patients fulfilled the criteria of severe sepsis and the International Society on Thrombosis and Haemostasis criteria for overt DIC. The initial 45 patients were treated without rhTM (control group), and the following 20 consecutive patients were treated with rhTM (0.06 mg/kg/day) for six days (rhTM group). The primary outcome measure was 28-day mortality. Stepwise multivariate Cox regression analysis was used to assess which independent variables were associated with mortality. Comparisons of Sequential Organ Failure Assessment (SOFA) score on sequential days between the two groups were analyzed by repeated measures analysis of variance. Results Cox regression analysis showed 28-day mortality to be significantly lower in the rhTM group than in the control group (adjusted hazard ratio, 0.303; 95% confidence interval, 0.106 to 0.871; P = 0.027). SOFA score in the rhTM group decreased significantly in comparison with that in the control group (P = 0.028). In the post hoc test, SOFA score decreased rapidly in the rhTM group compared with that in the control group on day 1 (P < 0.05). Conclusions We found that rhTM administration may improve organ dysfunction in patients with sepsis-induced DIC. Further clinical investigations are necessary to evaluate the effect of rhTM on the pathophysiology of sepsis-induced DIC.

Background In recent years, the measurement of cerebral regional oxygen saturation (rSO2) during resuscitation has attracted attention. The objective of this study was to clarify the relationship between the serial changes in the cerebral rSO2 values during extracorporeal cardiopulmonary resuscitation (ECPR) and the neurological outcome. Methods We measured the serial changes in the cerebral rSO2 values of patients with out-of-hospital cardiac arrest before and after ECPR in Osaka National Hospital. Results From January 2013 through March 2015, the serial changes in the cerebral rSO2 values were evaluated in 16 patients. Their outcomes, as measured by the Glasgow Outcome Scale (GOS) score at discharge, included good recovery (GR) (n = 4), vegetative state (VS) (n = 2), and death (D) (n = 10). In the poor neurological group (VS and D: n = 12; age, 52.8 ± 4.0 years), the cerebral rSO2 values showed a significant increase during ECPR (5 min before ECPR: 52.0 ± 1.8%; 2 min before ECPR: 56.1 ± 2.3%; 2 min after ECPR: 63.5 ± 2.2%; 5 min after ECPR: 66.4 ± 2.2%; 10 min after ECPR: 67.6 ± 2.3% [P

Background Bicycle accidents are one of the major causes of unintentional traumatic injury in childhood. The purpose of this study was to examine characteristics and risks of handlebar injury in childhood. Methods We conducted a more than 5-year retrospective survey of patients under 15 years of age with bicycle-related injuries admitted to eight urban tertiary emergency centers in Osaka, Japan. Patients were divided into the direct-impact handlebar injury (HI) group and the non-handlebar injury (NHI) group. Results The HI group included 18 patients and the NHI group included 308 patients. Median Injury Severity Score (ISS) in the HI group was 9. Injury sites included the chest, 2 (chest bruise, 1; tracheal injury, 1) and abdomen, 16 (hepatic injury, 6; pancreatic injury, 2; duodenal injury, 1; splenic injury, 1; small intestinal injury, 1; retroperitoneal hemorrhage, 1; renal injury, 1; abdominal wall musculature injury, 2; bladder injury, 1; and perineal laceration, 1). There were no significant differences in age, sex, ISS, and prognosis between the two groups. However, significant differences were seen in the abdominal median Abbreviated Injury Scale (AIS) score, which was higher in the HI group (3 vs 0, p