Association between the severity of hypothermia and in-hospital mortality in patients with infectious diseases: The J-Point registry

Aim

Hypothermia is associated with poor prognosis in patients with sepsis. However, no studies have explored the correlation between the severity of hypothermia and prognosis.

Methods

Using data from the Japanese accidental hypothermia network registry (J-Point registry), we examined adult patients aged ≥18 years with infectious diseases whose initial body temperature was ≤35°C from April 1, 2011 to March 31, 2016, in 12 centers. Patients were divided into three groups according to their body temperature: Tertile 1 (T1) (32.0-35.0°C), Tertile 2 (T2) (28.0-31.9°C), and Tertile 3 (T3) (<28.0°C). In-hospital mortality was employed as a metric to assess outcomes. We conducted a multivariate logistic regression analysis to investigate the relationship between the three categories and the occurrence of in-hospital mortality.

Results

A total of 572 patients were registered, and 170 eligible patients were identified. Of these patients, 55 were in T1 (32.0-35.0°C), 76 in T2 (28.0-31.9°C), and 39 in T3 (<28.0°C) groups. The overall in-hospital mortality rate in accidental hypothermia (AH) patients with infectious diseases was 34.1%. The in-hospital mortality rates in the T1, T2, and T3 groups were 34.5%, 36.8%, and 28.2%, respectively. The multivariable analysis demonstrated no significant differences regarding in-hospital mortality among the three groups (T2 vs. T1, adjusted odds ratio [OR]: 1.29; 95% confidence interval [CI]: 0.58-2.89 and T3 vs. T1, adjusted OR: 0.83; 95% CI: 0.30-2.31).

Conclusion

In this multicenter retrospective observational study, hypothermia severity was not associated with in-hospital mortality in AH patients with infectious diseases.

Prediction of clinical outcomes in patients with coronavirus disease 2019 using high-sensitive troponin I and N-terminal pro-B-type natriuretic peptide

Background

Several comorbidities, including cardiovascular diseases or myocardial injury, are reported to be associated with poor prognosis in patients with Coronavirus disease 2019 (COVID-19). However, detailed prognostic analysis of myocardial injury by various biomarkers in COVID-19 patients is limited.

Purpose

This study aims to explore the prognostic values of high-sensitive Troponin I (hsTnI) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) for COVID-19 patients using Japanese real-world data.

Methods

The COVID-MI study is a retrospective cohort study that enrolls consecutive laboratory-confirmed COVID-19 patients admitted to the hospital from July 2020 to September 2021. We collected clinical data, including cardiac biomarker values, by chart review. If the prespecified biomarkers in concern were not available, we measured them using the institutional serum blood bank, which enrolled patients prospectively from July 2020. Patients with available biomarkers were analyzed according to the values of hsTnI or NT-proBNP, using the clinically relevant thresholds (hsTnI: 5 ng/L and 99th percentile of the upper reference limit [99%ile URL], and NT-proBNP: 125 pg/mL and 900 pg/mL). The primary outcome measure was all-cause death. Secondary outcome measures included acute respiratory distress syndrome, myocardial infarction, myocarditis/pericarditis, venous thromboembolism, cerebral infarction, and bleeding events.

Results

We enrolled 917 patients with COVID-19 confirmed by viral nucleic acid amplification test. The mean age was 61 years, and 591 patients (64%) were men. On admission, the number of patients classified as severe or critical COVID-19 was 515 (56%) and 85 (8.7%), respectively. Among the 544 patients with hsTnI values, 365 (67%) patients had elevated hsTnI of ≥5 ng/L, and 134 patients (25%) had TnI of ≥99%ile URL. Besides, among 546 patients with NT-proBNP values, 295 patients (54%) had elevated NT-pro-BNP of ≥125 pg/mL, and 93 patients (17%) had NT-proBNP of ≥900 pg/mL. The median follow-up period was 31 days (interquartile range: 11–90 days). In cumulative incidence analysis, higher levels of hsTnI and NT-proBNP were associated with significantly higher mortality (hsTnI: &lt;5 ng/L group; 8.8%, 5 ng/L to 99%ile URL group; 19%, and ≥99%ile URL group; 37%, P&lt;0.001, and NT-proBNP: &lt;125 pg/mL group; 7.8%, 125 to 900 pg/mL group; 21%, and ≥900 pg/mL group; 45%, P&lt;0.001). The adjusted risk for all-cause death remained significant for each threshold of cardiac biomarkers (hsTnI ≥99%ile URL: hazard ratio [HR] 1.98, 95% confidence interval [CI] 1.11–3.54, P=0.02, and NT-proBNP ≥900 pg/mL: HR 3.60, 95% CI 1.86–6.98, P&lt;0.001).

Conclusion

Elevation of hsTnI or NT-proBNP was associated with poor prognosis in the current relatively severely ill COVID-19 patients. Measuring hsTnI or NT-proBNP can be an attractive option for risk stratification and deciding appropriate management in patients with COVID-19.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Institutional Research Fund at Kobe City Medical Center General Hospital

Clinical relevance of impaired consciousness in accidental hypothermia: a Japanese multicenter retrospective study

Aim

This study aimed to investigate the association between level of impaired consciousness and severe hypothermia (<28°C) and to evaluate the association between level of impaired consciousness and inhospital mortality among accidental hypothermia patients.

Methods

This was a multicenter retrospective study using the J‐Point registry database, which includes data regarding patients whose core body temperature was 35.0°C or less and who were treated as accidental hypothermia in emergency departments between April 1, 2011 and March 31, 2016. We estimated adjusted odds ratios of the level of impaired consciousness for severe hypothermia less than 28°C and inhospital mortality using a logistic regression model.

Results

The study included 505 of 572 patients in the J‐Point registry. Relative to mildly impaired consciousness (Glasgow Coma Scale [GCS] 13–15), the adjusted odds ratios for severe hypothermia less than 28°C were: moderate (GCS 9–12), 3.26 (95% confidence interval [CI], 1.69–6.25); and severe (GCS < 9), 4.68 (95% CI, 2.40–9.14). Relative to mildly impaired consciousness (GCS 13–15), the adjusted odds ratios for inhospital mortality were: moderate (GCS9–12), 1.65 (95% CI, 0.95–2.88); and severe (GCS < 9), 2.10 (95% CI, 1.17–3.78).

Conclusion

The level of impaired consciousness in patients with accidental hypothermia was associated with severe hypothermia and inhospital mortality.

Machine learning-based prediction models for accidental hypothermia patients

Background

Accidental hypothermia is a critical condition with high risks of fatal arrhythmia, multiple organ failure, and mortality; however, there is no established model to predict the mortality. The present study aimed to develop and validate machine learning-based models for predicting in-hospital mortality using easily available data at hospital admission among the patients with accidental hypothermia.

Method

This study was secondary analysis of multi-center retrospective cohort study (J-point registry) including patients with accidental hypothermia. Adult patients with body temperature 35.0 °C or less at emergency department were included. Prediction models for in-hospital mortality using machine learning (lasso, random forest, and gradient boosting tree) were made in development cohort from six hospitals, and the predictive performance were assessed in validation cohort from other six hospitals. As a reference, we compared the SOFA score and 5A score.

Results

We included total 532 patients in the development cohort [N = 288, six hospitals, in-hospital mortality: 22.0% (64/288)], and the validation cohort [N = 244, six hospitals, in-hospital mortality 27.0% (66/244)]. The C-statistics [95% CI] of the models in validation cohorts were as follows: lasso 0.784 [0.717–0.851] , random forest 0.794[0.735–0.853], gradient boosting tree 0.780 [0.714–0.847], SOFA 0.787 [0.722–0.851], and 5A score 0.750[0.681–0.820]. The calibration plot showed that these models were well calibrated to observed in-hospital mortality. Decision curve analysis indicated that these models obtained clinical net-benefit.

Conclusion

This multi-center retrospective cohort study indicated that machine learning-based prediction models could accurately predict in-hospital mortality in validation cohort among the accidental hypothermia patients. These models might be able to support physicians and patient’s decision-making. However, the applicability to clinical settings, and the actual clinical utility is still unclear; thus, further prospective study is warranted to evaluate the clinical usefulness.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40560-021-00525-z.

Biodegradable-polymer versus durable-polymer drug eluting stents for coronary artery disease: systematic review and a meta-analysis

Background

Biodegradable polymer drug-eluting stents (BP-DES) has been developed to overcome the potential drawbacks of the first-generation durable polymer drug-eluting stents (DP-DES). However, it is still under debate whether BP-DES is associated with superior efficacy and safety over DP-DES.

Purpose

We sought to compare the effects of BP-DES and DP-DES in patients with coronary artery disease.

Methods

We performed systematic review and a meta-analysis of randomized controlled trials comparing BP-DES and DP-DES on clinical outcomes in patients with coronary artery disease using CE-mark approved drug-eluting stents (DES) with at least 1-year follow-up. We included 32 studies involving 39,686 patients (BP-DES: 21,439 patients, and DP-DES: 18,247 patients). Primary outcome measure was target vessel failure (TVF; equivalent to the composite of cardiac death, target-vessel myocardial infarction, or ischemia-driven target vessel revascularization). We performed subgroup analysis according to the DP-DES generations (newer-generation DP-DES: 15,179patients, and first-generation DP-DES: 3,068 patients), and the effects of newer-generation DP-DES was compared with the BP-DES according to the BP-DES strut thickness (Ultra-thin strut [&lt;80μm]: 7,572 patients, Thin-strut [80–100μm]: 5,465 patients, and Thick-strut [≥80μm]: 5,876 patients).

Results

The odds for TVF was not significantly different between the BP-DES group and the DP-DES group in the entire study population (odds ratio [OR] 0.96, 95% confidence interval [CI] [0.90–1.02], P=0.20). The odds for TVF was significantly low in the BP-DES group relative to the first-generation DP-DES group, however the odds were comparable between the BP-DES group and the newer-generation DP-DES group (BP-DES versus first-generation DP-DES: OR 0.82, 95% CI [0.73–0.92], P&lt;0.001, and BP-DES versus newer-generation DP-DES: OR 1.00, 95% CI [0.93–1.08], P=0.99). We also found no significant differences between the BP-DES and newer-generation DP-DES, in all subgroups stratified by the BP-DES strut thickness (Ultra-thin strut BP-DES versus newer-generation DP-DES: OR 0.88, 95% CI [0.76–1.02], P=0.10, Thin-strut BP-DES versus newer-generation DP-DES: OR 1.01, 95% CI [0.90–1.13], P=0.89, and Thick strut BP-DES versus newer-generation DP-DES: OR 1.11, 95% CI [0.99–1.25], P=0.08).

Conclusions

In this meta-analysis of randomized controlled trials evaluating clinical outcomes, there was no significant differences between BP-DES and DP-DES. We found beneficial effects of BP-DES relative to the first-generation DP-DES, however, there was no statistical differences between BP-DES and newer-generation DP-DES, irrespective of the BP-DES strut thickness.

Pooled odds ratios for clinical outcomes

Funding Acknowledgement

Type of funding source: None

Care at critical care medical centers is associated with improved outcomes in patients with accidental hypothermia: a historical cohort study from the J-Point registry

Aim

The recommendation that patients with accidental hypothermia should be transported to specialized centers that can provide extracorporeal life support has not been validated, and the efficacy remains unclear.

Methods

This was a multicenter retrospective cohort study of patients with a body temperature of ≤35°C presenting at the emergency department of 12 hospitals in Japan between April 2011 and March 2016. We divided the patients into two groups based on the point of care delivery: critical care medical center (CCMC) or non‐CCMC. The primary outcome of this study was in‐hospital death. In‐hospital death was compared using a multivariable logistic regression analysis. Subgroup analyses were carried out according to patients with severe hypothermia (<28°C) or systolic blood pressure (sBP) of <90 mmHg.

Results

A total of 537 patients were included, 413 patients (76.9%) in the CCMC group and 124 patients (23.1%) in the non‐CCMC group. The in‐hospital death rate was lower in the CCMC group than in the non‐CCMC group (22.3% versus 31.5%, P < 0.001). The multivariable logistic regression analysis showed that the adjusted odds ratio (AOR) of the CCMC group was 0.54 (95% confidence interval, 0.32–0.90). In subgroup analyses, patients with systolic blood pressure <90 mmHg in the CCMC group were less likely to experience in‐hospital death (AOR 0.36; 95% CI, 0.23–0.56). However, no such association was observed among patients with severe hypothermia (AOR 1.08; 95% CI, 0.63–1.85).

Conclusions

Our multicenter study indicated that care at a CCMC was associated with improved outcomes in patients with accidental hypothermia.

Osborn Wave Is Related to Ventricular Fibrillation and Tachycardia in Hypothermic Patients

BACKGROUND

The Osborn wave (OW) is often observed in hypothermic patients; however, whether OW in hypothermic patients is related to the development of fatal ventricular arrhythmia, including ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT), remains undetermined. This study aimed to estimate the association between OW and the incidence of fatal ventricular arrhythmias.Methods and Results: This retrospective study used the Japanese Accidental Hypothermia Network registry database and included 572 hypothermic patients. Patients were divided into the OW group (those with OW) and non-OW group (those without OW). The relationship between the development of fatal arrhythmias and presence of OW was assessed using the chi-squared test. All patients who developed VF/VT (n=10) had OW on electrocardiogram upon hospital arrival. The presence of OW had a sensitivity of 100%, specificity of 47.8%, positive predictive value of 4.0%, and negative predictive value of 100% for VF/VT development. The in-hospital mortality rate was 22.3% in the OW group and 21.2% in the non-OW group (P=0.781).

CONCLUSIONS

OW was observed in all hypothermic patients with VF/VT. The occurrence of ventricular arrhythmias is highly unlikely in the absence of OW on the electrocardiogram. Although the presence of OW might be used to predict these fatal arrhythmias in hypothermic patients, there was no association between the presence of OW and in-hospital mortality.

Impact of rewarming rate on the mortality of patients with accidental hypothermia: analysis of data from the J-Point registry

BACKGROUND

Accidental hypothermia (AH) is defined as an involuntary decrease in core body temperature to < 35 °C. The management of AH has been progressing over the last few decades, and numerous techniques for rewarming have been validated. However, little is known about the association between rewarming rate (RR) and mortality in patients with AH.

METHOD

This was a multicentre chart review study of patients with AH visiting the emergency department of 12 institutions in Japan from April 2011 to March 2016 (Japanese accidental hypothermia network registry, J-Point registry). We retrospectively registered patients using the International Classification of Diseases, Tenth Revision code T68: 'hypothermia'. We excluded patients whose body temperatures were unknown or ≥ 35 °C, who could not be rewarmed, whose rewarmed temperature or rewarming time was unknown, those aged < 18 years, or who or whose family members had refused to join the registry. RR was calculated based on the body temperature on arrival at the hospital, time of arrival at the hospital, the documented temperature during rewarming, and time of the temperature documentation. RR was classified into the following five groups: ≥2.0 °C/h, 1.5-< 2.0 °C/h, 1.0-< 1.5 °C/h, 0.5-< 1.0 °C/h, and < 0.5 °C/h. The primary outcome of this study was in-hospital mortality. The association between RR and in-hospital mortality was evaluated using multivariate logistic regression analysis.

RESULT

During the study, 572 patients were registered in the J-Point registry, and 481 patients were included in the analysis. The median body temperature on arrival to the hospital was 30.7 °C (interquartile range [IQR], 28.2 °C-32.4 °C), and the median RR was 0.85 °C/h (IQR, 0.53 °C/h-1.31 °C/h). The in-hospital mortality rates were 19.3% (11/57), 11.1% (4/36), 14.4% (15/104), 20.1% (35/175), and 34.9% (38/109) in the ≥2.0 °C/h, 1.5-< 2.0 °C/h, 1.0-< 1.5 °C/h, 0.5-< 1.0 °C/h, and < 0.5 °C/h groups, respectively. Multivariate regression analysis revealed that in-hospital mortality rate increased with each 0.5 °C/h decrease in RR (adjusted odds ratio, 1.49; 95% confidence interval, 1.15-1.94; P_trend < 0.01).

CONCLUSION

This study showed that slower RR is independently associated with in-hospital mortality.

Prognostic ability of the sequential organ failure assessment score in accidental hypothermia: a multi-institutional retrospective cohort study

Background

Severe accidental hypothermia (AH) is life threatening. Thus, prognostic prediction in AH is essential to rapidly initiate intensive care. Several studies on prognostic factors for AH are known, but none have been established. We clarified the prognostic ability of the Sequential Organ Failure Assessment (SOFA) score in comparison with previously reported prognostic factors among patients with AH.

Methods

The J-point registry database is a multi-institutional retrospective cohort study for AH in 12 Japanese emergency departments. From this registry, we enrolled patients who were treated at the intensive care unit (ICU) in various critical care medical centers. In-hospital mortality was the primary outcome. We investigated the discrimination ability of each candidate prognostic factor and the in-hospital mortality by applying the logistic regression models with areas under the receiver operating characteristic curve (AUROC) with 95% confidence interval (CI).

Results

Of the 572 patients with AH registered in the J-point registry, 220 were eligible for the analyses. The in-hospital mortality was 23.2%. The AUROC of the SOFA score (0.80; 95% CI: 0.72–0.86) was the highest among all factors. The other factors were serum potassium (0.65; 95% CI: 0.55–0.73), lactate (0.67; 95% CI: 0.57–0.75), quick SOFA (qSOFA) (0.55; 95% CI: 0.46–0.65), systemic inflammatory response syndrome (SIRS) (0.60; 95% CI: 0.50–0.69), and 5A severity scale (0.77; 95% CI: 0.68–0.84).

Discussion

Although serum potassium and lactate had relatively good discrimination ability as mortality predictors, the SOFA score had slightly better discrimination ability. The reason is that lactate and serum potassium were mainly reflected by the hemodynamic state; conversely, the SOFA score is a comprehensive score of organ failure, basing on six different scores from the respiratory, cardiovascular, hepatic, coagulation, renal, and neurological systems. Meanwhile, the qSOFA and SIRS scores underestimated the severity, with low discrimination abilities for mortality.

Conclusions

The SOFA score demonstrated better discrimination ability as a mortality predictor among all known prognostic factors in patients with AH.

Correction to: The development and validation of a "5A" severity scale for predicting in-hospital mortality after accidental hypothermia from J-point registry data

[This corrects the article DOI: 10.1186/s40560-019-0384-2.].

The development and validation of a "5A" severity scale for predicting in-hospital mortality after accidental hypothermia from J-point registry data

Background

Accidental hypothermia is a serious condition that requires immediate and accurate assessment to determine severity and treatment. Currently, accidental hypothermia is evaluated using the Swiss grading system which uses core body temperature and clinical findings; however, research has shown that core body temperature is not associated with in-hospital mortality in urban settings. Therefore, we developed and validated a severity scale for predicting in-hospital mortality among urban Japanese patients with accidental hypothermia.

Methods

Data for this multi-center retrospective cohort study were obtained from the J-point registry. We included patients with accidental hypothermia who were admitted to an emergency department. The total cohort was divided into a development cohort and validation cohort, based on the location of each institution. We developed a logistic regression model for predicting in-hospital mortality using the development cohort and assessed its internal validity using bootstrapping. The model was then subjected to external validation using the validation cohorts.

Results

Among the 572 patients in the J-point registry, 532 were ultimately included and divided into the development cohort (N = 288, six hospitals, in-hospital mortality 22.0%) and the validation cohort (N = 244, six hospitals, in-hospital mortality 27.0%). The 5 “A” scoring system based on age, activities-of-daily-living status, near arrest, acidemia, and serum albumin level was developed based on the variables’ coefficients in the development cohort. In the validation cohort, the prediction performance was validated.

Conclusion

Our “5A” severity scoring system could accurately predict the risk of in-hospital mortality among patients with accidental hypothermia.

Electronic supplementary material

The online version of this article (10.1186/s40560-019-0384-2) contains supplementary material, which is available to authorized users.

Prevalence and outcomes of accidental hypothermia among elderly patients in Japan: Data from the J-Point registry

AIM

We aimed to evaluate the prevalence and outcomes of accidental hypothermia (AH) among elderly patients in Japan.

METHODS

This was a multicenter chart review study of patients with AH (Japanese accidental hypothermia network registry; J-Point registry) that included patients with a body temperature ≤35 °C and those aged ≥18 years who visited the emergency department of 12 institutions in Japan from 1 April 2011 to 31 March 2016. The patients were classified into three groups: adult (aged 18-64 years), young-old (aged 65-79 years) and old-old (aged ≥80 years). The association between each age category and in-hospital mortality from AH was examined through a multivariable logistic regression analysis.

RESULTS

In total, 572 patients were registered in the J-Point registry database, of which 537 were included. The proportion of individuals who developed AH in an indoor setting was higher in the old-old group than in the adult group (86.9% [226/260] vs 61.1% [87/113]). The in-hospital mortality rates of the adult, young-old and old-old groups were 15.0% (17/113), 21.3% (35/164) and 30.4% (79/260), respectively. In the multivariable analysis, the in-hospital mortality rate was higher in the young-old and old-old groups than in the adult group (young-old vs adult, adjusted odds ratio: 2.31 and 95% confidence interval 1.16-4.64; old-old vs adult, adjusted odds ratio: 2.91 and 95% confidence interval 1.41-6.02).

CONCLUSIONS

Approximately 80% of patients with AH were aged ≥65 years. The in-hospital mortality rate of patients aged ≥65 years was significantly higher than that of those aged <65 years. Geriatr Gerontol Int 2018; 18: 1427-1432.

Prognostic factors for patients with accidental hypothermia: A multi-institutional retrospective cohort study

INTRODUCTION

In cases of severe accidental hypothermia (AH) in urban areas, the prognostic factors are unknown. We identified factors associated with in-hospital mortality in patients with moderate-to-severe AH in urban areas of Japan.

METHOD

The J-Point registry database is a multi-institutional retrospective cohort study for AH in 12 Japanese emergency departments. From this registry, we enrolled patients whose core body temperature was 32 °C or less on admission. In-hospital death was the primary outcome of this study. We investigated the association between each candidate prognostic factor and in-hospital death by applying the multivariate logistic regression analyses with adjusted odds ratios (AORs) and their 95% confidence interval [CI] as the effect variables.

RESULTS

Of 572 patients registered in the J-point registry, 358 hypothermic patients were eligible for analyses. Median body temperature was 29.2 °C (interquartile range, 27.0 °C-30.8 °C). In-hospital deaths comprised 26.3% (94/358) of all study patients. Factors associated with in-hospital death were age ≥ 75 years (AOR, 3.09; 95% CI, 1.31-7.27), need for assistance with activities of daily living (ADL; AOR, 3.06; 95% CI, 1.68-5.59), hemodynamic instability (AOR, 2.49; 95% CI, 1.32-4.68), and hyperkalemia (≥5.6 mEq/L; AOR, 2.65; 95% CI, 1.13-6.21).

CONCLUSION

The independent prognostic factors associated with in-hospital mortality of patients with moderate-to-severe AH in urban areas of Japan were age ≥ 75 years, need for assistance with ADL, hemodynamic instability, and hyperkalemia.

Characteristics and outcomes of accidental hypothermia in Japan: the J-Point registry

BACKGROUND

Accidental hypothermia (AH) has higher incidence and mortality in geriatric populations. Japan has a rapidly ageing population, and little is known about the epidemiology of hypothermia in this country.

METHODS

We created an AH registry based on retrospective review of patients visiting the ED of 12 institutions with temperature ≤35°C between April 2011 and March 2016. The severity of AH was classified as mild (≤35, ≥32°C), moderate (<32, ≥28°C) or severe (<28°C). The relationship between in-hospital mortality and severity of AH was assessed using a multivariable logistic regression analysis.

RESULTS

A total of 572 patients were registered in this registry and 537 patients were eligible for our analysis. The median age was 79 (IQR 66-87) years and the proportion of men was 51.2% (273/537). AH was more likely to occur in elderly patients aged ≥65 years (424/537, 80.0%) and in indoor settings (418/537, 77.8%). The condition most frequently associated with AH, irrespective of severity, was acute medical illness. A lower mean outside temperature was associated with a higher prevalence of AH, and particularly severe AH (p for trend <0.001). The overall proportion of cases resulting in in-hospital death was 24.4% (131/537), with no significant difference between severity levels observed in a multivariable logistic regression analysis (severe group (37/118, 31.4%) vs mild group (42/192, 21.9%), adjusted OR (AOR) 1.01, 95% CI 0.61 to 1.68; and moderate group (52/227, 22.9%) vs mild group, AOR 1.11, 95% CI 0.58 to 2.14).

CONCLUSION

Active prevention and intervention should occur for this important public health issue.

The relationship between cerebral regional oxygen saturation during extracorporeal cardiopulmonary resuscitation and the neurological outcome in a retrospective analysis of 16 cases

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 < 0.01]). In contrast, in the good neurological group (GR: n = 4; age, 53.8 ± 6.9 years), the cerebral rSO₂ values did not increase to a significant extent during ECPR (5 min before ECPR: 61.9 ± 3.1%; 2 min before ECPR: 57.1 ± 4.0%; 2 min after ECPR: 59.6 ± 3.8%; 5 min after ECPR: 61.0 ± 3.7%; 10 min after ECPR: 62.0 ± 3.8% [P = 0.88]). Our study suggested that the patients whose cerebral rSO₂ values showed no significant improvement after ECPR might have had a good neurological prognosis.

Conclusions

The serial changes in the cerebral rSO₂ values during ECPR may predict a patient’s neurological outcome. The further evaluation of the validity of rSO₂ monitoring during ECPR may lead to a new resuscitation strategy.

Pre-hospital portable monitoring of cerebral regional oxygen saturation (rSO2) in seven patients with out-of-hospital cardiac arrest

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.

Temporal intrailiac balloon occlusion for the treatment of intractable pelvic fracture hemorrhage

Case

A 48-year-old schizophrenic man sustained multiple injuries following a fall. Unstable pelvic fractures were diagnosed in the emergency department. The patient's hemodynamic status was stabilized following bilateral internal iliac artery embolization using a gelatin sponge. However, recurrent bleeding and an expanding retroperitoneal hemorrhage occurred 1 h after transcatheter arterial embolization.

Outcome

Using temporal intrailiac balloon occlusion, with preperitoneal gauze packing, the patient's hemodynamic status was stabilized in the intensive care unit. No complications were observed following transcatheter arterial embolization and balloon occlusion.

Conclusions

Temporary intrailiac balloon occlusion is a rapid and safe treatment for refractory pelvic hemorrhage, which can be administered simultaneously with other treatments including preperitoneal gauze packing and external fixation.

Negative pressure wound therapy-assisted dermatotraction for the closure of large open wounds in a patient with non-clostridial gas gangrene

Case

A 53-year-old woman developed septic shock associated with non-clostridial gas gangrene. She presented to the emergency department with two large open wounds on both thighs and in her sacral region. Non-enhanced computed tomography showed air density in contact with the right iliopsoas, which extended to the posterior compartment of the thigh. We made repeated efforts at surgical debridement of the wound with resection of necrotic tissues.

Outcome

Using negative pressure wound therapy-assisted dermatotraction, the pus pockets and the wound dehiscence decreased in size. Using this method we were successful in achieving delayed closure without skin grafts.

Conclusion

Negative pressure wound therapy can be an effective treatment for large and infected open contoured wounds. Negative pressure wound therapy-assisted dermatotraction might be beneficial for poorly healing, large, open wounds in patients in poor condition and with insufficient reserve to tolerate reconstructive surgery.

Correlation of CT values, iodine concentration, and histological changes in the thyroid

PURPOSE

We have reported that in the thyroid, there is a linear correlation between iodine concentrations and CT values. However, the slope of the regression line was about three times as large as that in KI solutions. We investigated the factor(s) contributing to the increment of the slope of the regression line in the thyroid.

METHOD

Solutions of NH4I and thyroid hormones were used to investigate the regression line. Thirty-six thyroids were evaluated to investigate the correlation between the iodine concentrations and the area ratio of thyroid follicles, which were measured by preoperative CT and from tissue slices, respectively.

RESULTS

The slopes of the regression lines in the solutions were almost identical to those in KI solutions. In the thyroid, iodine concentrations were logarithmically correlated with the area ratio of follicles.

CONCLUSION

The decrease in CT values not only revealed a decrease of iodine concentration in the thyroid but also represented an increase of follicular cells and/or interstitial structures in the volume ratio secondary to it.

Acinar cell carcinoma of the pancreas associated with hypoglycemia: involvement of "big" insulin-like growth factor-II

Apart from insulinomas, pancreatic tumors are rarely complicated by hypoglycemia and some may produce insulin-like growth factor II (IGF-II). To our knowledge, IGF-II-producing pancreatic tumors associated with hypoglycemia have not been reported previously. We describe what we believe to be the first case of "big" IGF-II-producing pancreatic acinar cell carcinoma. A 68-year-old man presented with a history of recurrent hypoglycemia. Abdominal computed tomography scan and magnetic resonance imaging showed a mass, approximately 5 cm in diameter, in the tail of the pancreas and two low-density areas in the liver. Low serum glucose was associated with low insulin levels and high levels of hormones (i.e., glucagon and IGF-II) that are functionally opposite to insulin. Although serum IGF-II level was within the normal range, most IGF-II was of the high molecular weight form, as determined by Western immunoblot analysis. Based on these findings, a diagnosis of hypoglycemia induced by IGF-II-producing pancreatic tumor was made. Surgery was not possible because of the patient's poor general condition. The patient ultimately died as a result of malignant cachexia. At autopsy, a yellowish-white tumor was found in the tail of the pancreas, and a histopathologic diagnosis of acinar cell carcinoma was made. Immunohistologically, the tumor cells contained IGF-II in an irregular staining pattern, suggesting that the hypoglycemia was caused by a pancreatic tumor producing "big" IGF-II.

[A study of ambulatory treatment for pulmonary tuberculosis in foreigners residing in Japan]

We studied 130 cases of pulmonary tuberculosis in foreigners residing in Japan to obtain the results as follows; 1. Of the cases of pulmonary tuberculosis in foreigners who are registered and receiving treatment in Japan, 20.3% were treated at three dispensaries of the Japan Antituberculosis Association in Tokyo. 2. The nationality of the cases treated was China in more than half of them, followed by the Republic of Korea. 3. The number of days taken from entry into Japan to the start of treatment was about 11.4 months; 0.9% of the total number of cases examined by chest radiophotography required medical treatment. 4. Their living conditions in Japan according to questionnairing are: 56.2% have jobs in Japan; working hour, 4.99 +/- 1.19 hours a day; 64.4% take night work; 57.6% work in food/drink service industry; living space is 12.5 m2; 52.4% share the same house with other persons, living together with 1.6 persons. 5. As for the type of illness at the start of treatment, GAKKAI classification type III accounted for 90% and spread 1 83.8%. GAKKAI classification type II accounted for 10%, consisting of many relatively mild cases. 6. The defaulter rate was high at 40.8%. The reason for defaulting was broken down to discontinuation on his own 68%, repatriation 15% and side-effects 19%. The time to default was average 3.2 +/- 3.1 months after the start of treatment. They defaulted 1.2 +/- 0.4 times on the average. 7. To reduce the defaulter rate to the minimum in treating the foreigners residing in Japan, the following may be needed. a. To give guidance on the regimen including the need of treatment and risk associated with discontinuation of treatment at the first visit. b. Measures to reduce the amount to be born by the individual in the medical expenses. c. Preparation of a pamphlet for therapeutic guidance in foreign languages.