The purpose of this study was to examine whether the temperature difference between the jugular bulb and pulmonary artery (ΔTjb-pa) is associated with the neurological outcome of patients with severe ...traumatic brain injury (TBI).
We conducted a post hoc analysis of a multicenter randomized controlled trial of mild therapeutic hypothermia (TH, 32.0-34.0°C) or fever control (FC, 35.5-37.0°C) for the patients with severe TBI. ΔTjb-pa averaged every 12 h and the variation in ΔTjb-pa were compared between patients with favorable (n = 39) and unfavorable (n = 37) neurological outcomes. These values were also compared in the TH and FC subgroups.
The average ΔTjb-pa values in patients with favorable and unfavorable outcomes were 0.24 ± 0.23 and 0.06 ± 0.36°C, respectively (P < 0.001). ΔTjb-pa trended significantly higher in the favorable outcome patients than in the unfavorable outcome patients throughout the 120 h after onset of severe TBI (P < 0.001). The variation in ΔTjb-pa from 0 to 72 h was significantly lower in the favorable outcome patients than in the unfavorable outcome patients (0.8 ± 0.8 vs 1.8 ± 2.5°C, respectively, P = 0.013). From 72 to 120 h, there was no significant difference in the variation in ΔTjb-pa. Significant differences between patients with favorable and unfavorable outcomes in ΔTjb-pa and the variation in ΔTjb-pa were similar in the TH subgroup, but not evident in the FC subgroup.
A reduction in ΔTjb-pa and greater variation in ΔTjb-pa were associated with an unfavorable outcome in patients with severe TBI, especially those treated with TH. When treating severe TBI patients, it is important to understand that there will be differences in temperature reflecting the brain environment and the systemic temperature, depending on the severity and outcome of TBI during TH.
Background Target temperature management (TTM) is an effective component of treating out-of-hospital cardiac arrest (OHCA) after return of spontaneous circulation in conventional cardiopulmonary ...resuscitation. However, therapeutic hypothermia (32-34 degreesC TTM) is not recommended based on the results of recent studies. Extracorporeal cardiopulmonary resuscitation (ECPR) with veno-arterial extracorporeal membrane oxygenation is another promising therapy for OHCA, but few studies have examined the effectiveness of ECPR with TTM. Therefore, we hypothesized that ECPR with TTM could have the effectiveness to improve the neurological outcomes for adults following witnessed OHCA, in comparison to ECPR without TTM. Methods We performed retrospective subanalyses of the Japanese Association for Acute Medicine OHCA registry. We focused on adults who underwent ECPR for witnessed OHCA. We performed univariate (the Mann-Whitney U test and Fisher's exact test), multivariable (logistic regression analyses), and propensity score analyses (the inverse probability of the treatment-weighting method) with to compare the neurological outcomes between patients with or without TTM, among all eligible patients, patients with a cardiogenic cause, and patients divided into subgroups according to the interval from collapse to pump start (ICPS) (> 30, > 45, or > 60 min). Results We analyzed data for 977 patients. Among 471 patients treated with TTM, the target temperature was therapeutic hypothermia in 70%, and the median interval from collapse to target temperature was 249 min. Propensity score analysis showed a positive association between TTM and favorable neurological outcomes in all patients (odds ratio 1.546 95% confidence interval 1.046-2.286, P = 0.029), and in patients with ICPS of > 30 or > 45 min, but not in those with ICPS of > 60 min. The propensity score analysis also showed a positive association between TTM and favorable neurological outcomes in patients with a cardiogenic cause (odds ratio 1.655 95% confidence interval 1.096-2.500, P = 0.017), including in all ICPS subgroups (> 30, > 45, and > 60 min). Conclusion Within patients who underwent ECPR following OHCA, ECPR with TTM could show the potential of improvement in the neurological outcomes, compared to ECPR without TTM. Keywords: Mild therapeutic hypothermia, Extracorporeal membrane oxygenation, Cerebral performance category
We herein report a 61-year-old man who sustained injury after a 2-m fall and developed mediastinitis. He presented to another hospital two days after the fall and was transferred to our hospital four ...days after the fall with a fever and dysphagia. Computed tomography revealed osteophytes on the second and third thoracic vertebrae and free air in the mediastinum, indicating esophageal perforation. Emergent surgery was performed. Intraoperatively, a longitudinal esophageal tear was identified. We stress the importance of being aware of the possibility of osteophyte-related esophageal perforation in patients with a history of a fall. A delayed diagnosis affects the prognosis.
Abstract
Heatstroke is a life-threatening event that affects people worldwide. Currently, there are no established tools to predict the outcomes of heatstroke. Although the Sequential Organ Failure ...Assessment (SOFA) score is a promising tool for judging the severity of critically ill patients. Therefore, in this study, we investigated whether the SOFA score could predict the outcome of patients hospitalized with severe heatstroke, including the classical and exertional types, by using data from a Japanese nationwide multicenter observational registry. We performed retrospective subanalyses of the Japanese Association for Acute Medicine heatstroke registry, 2019. Adults with a SOFA score ≥ 1 hospitalized for heatstroke were analyzed. We analyzed data for 225 patients. Univariate and multivariable analyses showed a significant difference in the SOFA score between non-survivors and survivors in classical and exertional heatstroke cases. The area under the receiver operating characteristic curve were 0.863 (classical) and 0.979 (exertional). The sensitivity and specificity of SOFA scores were 50.0% and 97.5% (classical), 66.7% and 97.5% (exertional), respectively, at a cutoff of 12.5, and 35.0% and 98.8% (classical), 33.3% and 100.0% (exertional), respectively, at a cutoff of 13.5. This study revealed that the SOFA score may predict mortality in patients with heatstroke and might be useful for assessing prognosis.
This case involved a 27-year-old man with extreme obesity (body mass index 45.6 kg/m2) who had a history of fulminant hepatitis and living-donor liver transplantation at 11 years of age. He had been ...receiving oral sustained-release tacrolimus (TAC) 1.5 mg daily, and the trough concentration in the blood was below 2.0 ng/mL. He has an intrinsic cytochrome P450 3A5 (CYP3A5)*3/*3 (G/G) genotype and graft liver with CYP3A5*3 allele donated by his biological father. Additionally, there were no data on the phenotype of P-glycoprotein. He did not take medications, grapefruit, or St. John’s wort, which interact with CYP3A4 and P-glycoprotein. He intentionally took 30 mg of TAC and presented with symptoms of general malaise and poisoning. On the day of hospitalization (day 0), TAC was discontinued due to an elevated blood TAC concentration of > 60 ng/mL. Additionally, the blood TAC concentration exceeded 10 ng/mL for more than 3 days. He exhibited mild elevation of alanine aminotransferase, aspartate aminotransferase, and creatinine phosphokinase without apparent clinical symptoms. After discharge, blood TAC concentration decreased to 7.4 and 3.7 ng/mL on days 14 and 28, respectively, from the day of excessive TAC intake. Finally, the blood TAC concentration fell below 2.0 ng/mL on day 66. This case report showed that extreme obesity and the liver CYP3A5*3 allele delayed the elimination of TAC after excessive intake of the drug.
Acute lung injury (ALI)/acute respiratory distress syndrome (ARDS) is characterized by features other than increased pulmonary vascular permeability. Pulmonary vascular permeability combined with ...increased extravascular lung water content has been considered a quantitative diagnostic criterion of ALI/ARDS. This prospective, multi-institutional, observational study aimed to clarify the clinical pathophysiological features of ALI/ARDS and establish its quantitative diagnostic criteria.
The extravascular lung water index (EVLWI) and the pulmonary vascular permeability index (PVPI) were measured using the transpulmonary thermodilution method in 266 patients with PaO2/FiO2 ratio ≤ 300 mmHg and bilateral infiltration on chest radiography, in 23 ICUs of academic tertiary referral hospitals. Pulmonary edema was defined as EVLWI ≥ 10 ml/kg. Three experts retrospectively determined the pathophysiological features of respiratory insufficiency by considering the patients' history, clinical presentation, chest computed tomography and radiography, echocardiography, EVLWI and brain natriuretic peptide level, and the time course of all preceding findings under systemic and respiratory therapy.
Patients were divided into the following three categories on the basis of the pathophysiological diagnostic differentiation of respiratory insufficiency: ALI/ARDS, cardiogenic edema, and pleural effusion with atelectasis, which were noted in 207 patients, 26 patients, and 33 patients, respectively. EVLWI was greater in ALI/ARDS and cardiogenic edema patients than in patients with pleural effusion with atelectasis (18.5 ± 6.8, 14.4 ± 4.0, and 8.3 ± 2.1, respectively; P < 0.01). PVPI was higher in ALI/ARDS patients than in cardiogenic edema or pleural effusion with atelectasis patients (3.2 ± 1.4, 2.0 ± 0.8, and 1.6 ± 0.5; P < 0.01). In ALI/ARDS patients, EVLWI increased with increasing pulmonary vascular permeability (r = 0.729, P < 0.01) and was weakly correlated with intrathoracic blood volume (r = 0.236, P < 0.01). EVLWI was weakly correlated with the PaO2/FiO2 ratio in the ALI/ARDS and cardiogenic edema patients. A PVPI value of 2.6 to 2.85 provided a definitive diagnosis of ALI/ARDS (specificity, 0.90 to 0.95), and a value < 1.7 ruled out an ALI/ARDS diagnosis (specificity, 0.95).
PVPI may be a useful quantitative diagnostic tool for ARDS in patients with hypoxemic respiratory failure and radiographic infiltrates.
UMIN-CTR ID UMIN000003627.
We aim to develop a deep-learning-based method for automatic proximal femur segmentation in quantitative computed tomography (QCT) images. We proposed a spatial transformation V-Net (ST-V-Net), which ...contains a V-Net and a spatial transform network (STN) to extract the proximal femur from QCT images. The STN incorporates a shape prior into the segmentation network as a constraint and guidance for model training, which improves model performance and accelerates model convergence. Meanwhile, a multi-stage training strategy is adopted to fine-tune the weights of the ST-V-Net. We performed experiments using a QCT dataset which included 397 QCT subjects. During the experiments for the entire cohort and then for male and female subjects separately, 90% of the subjects were used in ten-fold stratified cross-validation for training and the rest of the subjects were used to evaluate the performance of models. In the entire cohort, the proposed model achieved a Dice similarity coefficient (DSC) of 0.9888, a sensitivity of 0.9966 and a specificity of 0.9988. Compared with V-Net, the Hausdorff distance was reduced from 9.144 to 5.917 mm, and the average surface distance was reduced from 0.012 to 0.009 mm using the proposed ST-V-Net. Quantitative evaluation demonstrated excellent performance of the proposed ST-V-Net for automatic proximal femur segmentation in QCT images. In addition, the proposed ST-V-Net sheds light on incorporating shape prior to segmentation to further improve the model performance.
Hip fracture related to osteoporosis and metastatic disease is a major cause of morbidity and mortality. An accurate and precise method of predicting proximal femoral strength and fracture location ...would be useful for research and clinical studies of hip fracture. The goals of this study were to develop a structural modeling technique that accurately predicts proximal femoral strength; to evaluate the accuracy and precision of this predicted strength on an independent data set; and to evaluate the ability of this technique to predict fracture location. Fresh human cadaveric proximal femora with and without metastatic lesions were studied using computed tomography scan-based three-dimensional structural models and mechanical testing to failure under single-limb stance-type loading. The models understated proximal femoral strength by an average of 444 N, and the precision of the predicted strength was +/- 1900 N. Therefore, the ability to predict hip strength in an individual subject is limited primarily by the level of precision, rather than accuracy. This level of precision is likely to be sufficient for many studies of hip strength. Finally, these models predict fractures involving the subcapital and cervical regions, consistent with most fractures produced experimentally under single-limb stance-type loading.
Extracorporeal cardiopulmonary resuscitation (ECPR) with extracorporeal membrane oxygenation (ECMO) is a promising therapy for out-of-hospital cardiac arrest (OHCA) compared with conventional ...cardiopulmonary resuscitation (CCPR). The no and low-flow time (NLT), the interval from collapse to reperfusion to starting ECMO or to the return of spontaneous circulation (ROSC) in CCPR, is associated with the neurological outcome of OHCA. Because the effects of target temperature management (TTM) on the outcomes of ECPR are unclear, we compared the neurological outcomes of OHCA between ECPR and CCPR without TTM.
We performed retrospective subanalyses of the Japanese Association for Acute Medicine OHCA registry. Witnessed cases of adult cardiogenic OHCA without TTM were selected. We performed univariate, multivariable and propensity score analyses to compare the neurological outcomes after ECPR or CCPR in all eligible patients and in patients with NLT of > 30 min or > 45 min.
We analysed 2585 cases. Propensity score analysis showed negative result in all patients (odds ratio 0.328 95% confidence interval 0.141-0.761,
= 0.010). However, significant associated with better neurological outcome was shown in patients with NLT of > 30 min or > 45 min (odds ratio 2.977 95% confidence interval 1.056-8.388,
= 0.039, odds ratio 5.099 95% confidence interval 1.259-20.657,
= 0.023, respectively).
This study revealed significant differences in the neurological outcomes between ECPR and CCPR without TTM, in patients with NLT of > 30 min.
Purpose
Although the most recent systematic review and meta-analyses on acute respiratory distress syndrome (ARDS) have shown that the use of steroids decreases mortality in adult patients, its ...benefits and risks may differ depending on the type and dosage of the steroid. Therefore, we conducted a network meta-analysis (NMA) to compare the differences in the efficacy among different doses and types of steroids.
Methods
We searched MEDLINE, CENTRAL, ICHUSHI, ClinicalTrials.gov, and WHO ICTRP databases from the earliest records to March 2021 for randomized control trials, which compared steroids with placebo or conventional therapy for ARDS. Using the random-effects model, we compared various categories of steroids (high-dose methylprednisolone, low-dose methylprednisolone, hydrocortisone, dexamethasone, and no steroid) concerning hospital mortality, incidence of infection, and ventilator-free days (VFD).
Results
We analyzed nine studies involving adult patients (
n
= 1212). Although there were no significant differences between the groups in terms of the mortality and incidence of infection, the number of VFD were greater when using low-dose methylprednisolone than when not using any steroids (Mean difference: 6.06; 95% confidence intervals: 2.5, 10.5). Moreover, the rank probability showed that low-dose methylprednisolone might be the optimal treatment, whereas using no steroid or high-dose methylprednisolone may be inferior to other treatments in terms of mortality, infection, and VFD.
Conclusion
This NMA suggested that the effect of steroids on the outcome in patients with ARDS might depend on the type of the steroid drug administered. Moreover, further studies are needed to identify the optimal type and dosage.
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