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Abstract Background Hemodynamic stabilization is a core component in the resuscitation of septic shock. However, the optimal target blood pressure remains debatable. Previous randomized controlled trials suggested that uniformly adopting a target mean arterial pressure (MAP) higher than 65 mmHg for all adult septic shock patients would not be beneficial; however, it has also been proposed that higher target MAP may be beneficial for elderly patients, especially those with arteriosclerosis. Methods A multicenter, pragmatic single-blind randomized controlled trial will be conducted to compare target MAP of 80–85 mmHg (high-target) and 65–70 mmHg (control) in the resuscitation of septic shock patients admitted to 28 hospitals in Japan. Patients with septic shock aged ≥65 years are randomly assigned to the high-target or control groups. The target MAP shall be maintained for 72 h after randomization or until vasopressors are no longer needed to improve patients’ condition. To minimize the adverse effects related to catecholamines, if norepinephrine dose of ≥ 0.1 μg/kg/min is needed to maintain the target MAP, vasopressin will be initiated. Other therapeutic approaches, including fluid administration, hydrocortisone use, and antibiotic choice, will be determined by the physician in charge based on the latest clinical guidelines. The primary outcome is all-cause mortality at 90 days after randomization. Discussion The result of this trial will provide great insight on the resuscitation strategy for septic shock in the era of global aged society. Also, it will provide the better understanding on the importance of individualized treatment strategy in hemodynamic management in critically ill patients. Trial registration UMIN Clinical Trials Registry; UMIN000041775. Registered 13 September 2020. more...

Brugada syndrome (BS) is a genetic channelopathy syndrome that causes fatal cardiac dysrhythmias and sudden death. Fever and antiarrhythmics are aggravating factors of BS. There are many reports about BS preceded by fever but fewer reports on BS caused by hypercalcemia (HC). Here, we describe a unique case of BS preceded by concurrent fever and HC. A 46-year-old male visited the emergency department for malaise and fever. During admission, he suddenly developed cardiac arrest and ventricular fibrillation (VF). After resuscitation, electrocardiogram (ECG) showed “coved-type” ST elevation in V1 and V2, which led to the diagnosis of BS. This ST change declined after the fever subsided. He also had HC at the same time. After admission, he developed septic shock. We started treatment assuming that it was caused by the aggravation of ulcerative colitis, and liver abscess was revealed on contrast-enhanced computed tomography. After the infection was controlled, we implanted an implantable cardioverter defibrillator (ICD) and he was discharged. The cause of HC appeared to be an ectopic parathyroid adenoma, and calcium was normalized after tumor resection. In addition, this patient had nonfunctional pituitary adenoma and a nonfunctional adrenal tumor. His condition was indicative of multiple endocrine neoplasia type 1. This patient had BS presenting as VF induced by fever due to liver abscess and early repolarization, increasing the risk of arrhythmic events to carry out ICD implantation. HC can contribute to induce arrhythmia. more...

Abstract This work reports on a novel controlled nanocomposite fabrication technique which is applicable for material design via a micro- and nano-assembly method. The principle is based on the use of electrostatic adsorption of the surface charge-modified particles via layer-by-layer assembly. The polarity and the zeta potential of the surface charge was controlled using polycation and polyanion, while the zeta potential strength was controlled via the number of alternating coating layers which was determined using zeta potential measurement. A systematic study was conducted to demonstrate the feasibility of composite material assembly via electrostatic adsorption using alumina (Al2O3) and silica (SiO2) composite as a study model, which was carried out as a function of surface zeta potential, surface coverage percentage, and processing time. The considerable potential of this technique for composite material design is also further demonstrated with controlled assembly involving different materials in various structural forms such as fiber, whisker, nanosheets, and even irregular-shaped foam-like structured urethane. The composite materials designed using this EA method possess good potentials to be utilized for various applications such as mechanical property control, composite ceramic films formation, selective laser sintering, and rechargeable metal-air battery. more...

Background. Optimal treatment practices and factors associated with in-hospital mortality in spontaneous pneumothorax (SP) are not fully understood. We evaluated prevalence, clinical characteristics, and in-hospital mortality among Japanese patients with primary or secondary SP (PSP/SSP). Methods. We retrospectively reviewed and stratified 938 instances of pneumothorax in 751 consecutive patients diagnosed with SP into the PSP and SSP groups. Factors associated with in-hospital mortality in SSP were identified by multiple logistic regression analysis. Results. In the SSP group (n=327; 34.9%), patient age, requirement for emergency transport, and length of stay were greater (all, p more...

A 41-year-old man, a heavy drinker with no notable medical history, presented with fever and chest pain at the emergency department. His vital signs were a heart rate of 117 beats/min and oxygen saturation as measured by pulse oximetry 98% on 6 L/min via mask. His chest radiography and computed tomography revealed a left pneumothorax with massive pleural effusion (Figures 1A and 1B). Because he was highly obese, thoracic drain placement, done with forceps, was difficult. Thoracic drainage revealed a malodorous dark red pleural effusion. We diagnosed empyema with tension pneumothorax. The patient's respiratory condition improved after deaeration, and the chest drain was clamped after 1 L of effusion drainage because of concerns about reexpansion pulmonary edema. Five hours later, extensive erythema and swelling were observed around the drain site. When the drain was reopened, 0.5 L of drainage fluid was obtained. Ten hours later, computed tomography showed inflammatory findings with air in the subcutaneous and muscular layers that had not been present on admission (Figures 1C and 1D). The patient was considered to have developed gas gangrene caused by subcutaneous and muscular extension of pleural effusion triggered by thoracic drainage. After 30 hours of hospitalization, emergency debridement was performed. Caudal extension of skin and muscle necrosis from the drainage site was observed (Figure 1E). The necrosis was particularly pronounced around the fistula, which was different from the insertion site of the preoperative indwelling drain. This fistula was thought to have inadvertently resulted from blunt dissection with forceps. A new thoracic drain was inserted intraoperatively into this fistula (Figure 1F). The pleural fluid and muscle tissue culture findings showed Prevotella melaninogenica. After eight debridements, closed negative pressure wound therapy, and two skin grafts, the patient was transferred to another hospital on Day 116 of hospitalization. Very few cases of empyema with tension pneumothorax caused by gas-producing bacteria have been reported (1, 2). The possibility of gas-producing bacteria should be suspected when a malodorous pleural effusion is present. The frequency of reexpansion pulmonary edema has been reported to be less than 1% for drainage of pleural fluid greater than 1 L (3) and 16-33% for drainage of pneumothorax (4, 5). Thus, although it is a complication to be considered, it is transient and improves with conservative treatment. Gas gangrene, however, is irreversible and carries a high risk of death, with a mortality rate of 21.3% (6). Therefore, while noting the risk of reexpansion pulmonary edema, thorough drainage should be prioritized. Blunt dissection using a forceps resulted in the additional fistula, through which purulent pleural effusion spread outside the thoracic cavity. Thoracic drain placement via blunt dissection using a muscle hook is another option, but it carries a risk of side leakage if the hole is wider than the drain's diameter. The key point with either method is that initial thoracic drainage should be performed thoroughly to prevent the spread of infection outside the chest cavity. [ABSTRACT FROM AUTHOR] more...