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Context: The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score helps to diagnose necrotizing soft-tissue infection (NSTI). The LRINEC score has been reported to be associated with poor prognosis, although few studies have evaluated this association. Aims: We aimed to describe the characteristics of NSTI and assess whether the LRINEC score was associated with mortality and amputation. Settings and Design: We conducted a retrospective observational study from January 2007 to May 2018, in a Japanese tertiary care hospital. Subjects and Methods: Patients with NSTI were identified through our hospital database using the discharge diagnosis. We extracted data on patient characteristics, laboratory examinations, microbiological information, treatment, and in-hospital mortality. Statistical Analysis Used: We estimated the odds ratios (ORs) and associated 95% confidence intervals (CIs) for in-hospital mortality using logistic regression models. Results: We identified 58 patients. The median LRINEC score was 8 (interquartile range [IQR]: 6–9). Forty-four patients (75.9%) scored 6 or more. The eight patients with amputations had a median score of 6 (IQR: 4.5–7.5) versus 8 (IQR: 7–9) for patients who underwent debridement (P = 0.091). Survivors and nonsurvivors had median scores of 8 (IQR: 6–9) and 6 (IQR: 5–8), respectively (P = 0.148). The OR for mortality in patients with liver cirrhosis was 10.5 (95% CI: 1.00–110.36; P = 0.050). Conclusions: There was no association between the LRINEC score and patients' outcomes: mortality and amputation. Further studies are warranted to evaluate the utility of the LRINEC score and factors associated with poor prognosis in patients with NSTI.

Neuromuscular blocking agents play a significant role in improving the success rate for urgent intubation, although there is limited evidence about the effect on subsequent outcomes, such as the incidence of tracheostomy. In this retrospective cohort study, we aimed to examine the association between avoidance of neuromuscular blocking agents for urgent tracheal intubation and incidence of tracheostomy among patients in the intensive care unit (ICU). The setting of this study was an eight-bed ICU at a tertiary-care hospital in Okayama, Japan. We included patients who underwent urgent tracheal intubation at the emergency department or the ICU and were admitted to the ICU between April 2013 and November 2017. We extracted data on methods and medications of intubation, predictors for difficult intubation, Cormack–Lehane grade, patient demographics, primary diagnoses, reintubation. We estimated odds ratios and their 95% confidence intervals for elective tracheostomy during the ICU stay using logistic regression models. Of 411 patients, 46 patients underwent intubation without neuromuscular blocking agents and 61 patients underwent tracheostomy. After adjusting for potential confounders, patients who avoided neuromuscular blocking agents had more than double the odds of tracheostomy (odds ratio 2.59, 95% confidence interval 1.06–6.34, p value = 0.04). When stratifying the subjects by risk status for tracheostomy, the association was more pronounced in high-risk group, while we observed less significant association in the low-risk group. Avoidance of neuromuscular blocking agents for urgent intubation increases the risk of tracheostomy among emergency patients, especially those who have a higher risk for tracheostomy. Electronic supplementary material The online version of this article (10.1007/s11739-019-02214-0) contains supplementary material, which is available to authorized users.

Previous studies have reported the prevalence and risk factors of acute kidney injury (AKI) in relatively young trauma patients. The aims of this study were to identify the prevalence and risk factors of AKI among older Japanese trauma patients.We conducted a prospective observational study in the 8-bed intensive care unit (ICU) of a Japanese tertiary-care hospital. Participants comprised trauma patients aged 18 years or older admitted to the ICU. Our primary outcome was the incidence of AKI within 10days of admission, according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria.Among 333 patients, 66 (19.8%) developed AKI (Stage 1, n=54; Stages 2, n=5; and Stage 3, n=7). Multivariate logistic regression analysis revealed that the incidence of AKI was associated with increased age (odds ratio (OR), 1.38; 95% confidence interval (CI), 1.15-1.65), male sex (OR, 2.06; 95%CI, 1.04-4.07), greater amount of red blood cell transfusions (OR, 1.61; 95%CI, 1.04-1.17), and presence of underlying chronic kidney disease (CKD) (OR, 3.97; 95%CI, 1.78-8.83). Length of stay in the ICU was significantly longer in patients with AKI (6days) than in those without (3days; p0.001). Patients ≥65 years old were more likely to develop AKI (26.2% vs 11.6%; p0.001). No significant differences in ICU stay (median, 4 vs 4days; p=0.70), hospital stay (median, 24 vs 21days; p=0.45), or 28-day mortality (2.1% vs 1.4%; p=0.19) were evident between age groups.Approximately 20% of trauma patients developed AKI, and the elderly were more likely to develop AKI. Older age, male, greater units of red blood cell transfusions, and underlying CKD were associated with incidence of AKI.

Objective To examine whether peppy comments from attending physicians increased the workload of residents working in the emergency department (ED). Methods We conducted two parallel-group, assessor-blinded, randomized trials at the ED in a tertiary care hospital in western Japan. Twenty-five residents who examined either ambulatory (J(^o^)PAN-1 Trial) or transferred patients (J(^o^)PAN-2 Trial) in the ED on weekdays. Participants were randomly assigned to groups that either received a peppy message such as “Hope you have a quiet day!” (intervention group) or did not (control group) from the attending physicians. Both trials were conducted from June 2014 through March 2015. For each trial, residents rated the number of patients examined during and the busyness and difficulty of their shifts on a 5-point Likert scale. Results A total of 169 randomizations (intervention group, 81; control group, 88) were performed for the J(^o^)PAN-1 Trial, and 178 (intervention group, 85; control group, 93) for the J(^o^)PAN-2 Trial. In the J(^o^)PAN-1 trial, no differences were observed in the number of ambulatory patients examined during their shifts (5.5 and 5.7, respectively, p = 0.48), the busyness of their shifts (2.8 vs 2.8; p = 0.58), or the difficulty of their shifts (3.1 vs 3.1, p = 0.94). However, in the J(^o^)PAN-2 trial, although busyness (2.8 vs 2.7; p = 0.40) and difficulty (3.1 vs 3.2; p = 0.75) were similar between groups, the intervention group examined more transferred patients than the control group (4.4 vs 3.9; p = 0.01). Conclusions Peppy comments from attending physicians had a minimal jinxing effect on the workload of residents working in the ED. Trial Registration University Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR), UMIN000017193 and UMIN000017194.

Whether closed tracheal suctioning systems (CTSS) reduce the incidence of ventilator-associated pneumonia (VAP) compared with open tracheal suctioning systems (OTSS) is inconclusive. We conducted a systematic review and meta-analysis of randomized controlled trials that compared CTSS and OTSS. PubMed, the Cochrane Central Register of Controlled Trials, the Web of Science, Google Scholar, and a clinical trial registry from inception to October 2014 were searched without language restrictions. Randomized controlled trials of CTSS and OTSS that compared VAP in mechanically ventilated adult patients were included. The primary outcome was the incidence of VAP. Secondary outcomes were mortality and length of mechanical ventilation. Data were pooled using the random effects model. Sixteen trials with 1,929 participants were included. Compared with OTSS, CTSS was associated with a reduced incidence of VAP (RR 0.69; 95 % CI 0.54–0.87; Q = 26.14; I 2 = 46.4 %). Compared with OTSS, CTSS was not associated with reduction of mortality (RR 0.96; 95 % CI 0.83–1.12; Q = 2.27; I 2 = 0.0 %) or reduced length of mechanical ventilation (WMD −0.45 days; 95 % CI −1.25 to 0.36; Q = 6.37; I 2 = 5.8 %). Trial sequential analysis suggested a lack of firm evidence for 20 % RR reduction in the incidence of VAP. The limitations of this review included underreporting and low quality of the included trials, as well as variations in study procedures and characteristics. Based on current, albeit limited evidence, it is unlikely that CTSS is inferior to OTSS regarding VAP prevention; however, further trials at low risk of bias are needed to confirm or refute this finding.