Immediate Angiography and Decreased In-Hospital Mortality of Adult Trauma Patients: A Nationwide Study

PURPOSE

This study aimed to elucidate whether immediate angiography within 30 min is associated with lower in-hospital mortality compared with non-immediate angiography.

MATERIALS AND METHODS

We conducted a retrospective cohort study using a nationwide trauma databank (2019-2020). Adult trauma patients who underwent emergency angiography within 12 h after hospital arrival were included. Patients who underwent surgery before angiography were excluded. Immediate angiography was defined as one performed within 30 min after arrival (door-to-angio time ≤ 30 min). In-hospital mortality and non-operative management (NOM) failure were compared between patients with immediate and non-immediate angiography. Inverse probability weighting with propensity scores was conducted to adjust patient demographics, injury mechanism and severity, vital signs on hospital arrival, and resuscitative procedures. A restricted cubic spline curve was drawn to reveal survival benefits by door-to-angio time.

RESULTS

Among 1,455 patients eligible for this study, 92 underwent immediate angiography. Angiography ≤ 30 min was associated with decreased in-hospital mortality (5.0% vs 11.1%; adjusted odds ratio [OR], 0.42 [95% CI, 0.31-0.56]; p < 0.001), as well as lower frequency of NOM failure: thoracotomy and laparotomy after angiography (0.8% vs. 1.8%; OR, 0.44 [0.22-0.89] and 2.6% vs. 6.5%; OR, 0.38 [0.26-0.56], respectively). The spline curve showed a linear association between increasing mortality and prolonged door-to-angio time in the initial 100 min after arrival.

CONCLUSION

In trauma patients, immediate angiography ≤ 30 min was associated with lower in-hospital mortality and fewer NOM failures.

LEVEL OF EVIDENCE

Level 3b, non randomized controlled cohort/follow up study.

A novel prediction tool for mortality in patients with acute lower gastrointestinal bleeding requiring emergency hospitalization: a large multicenter study

The study aimed to identify prognostic factors for patients with acute lower gastrointestinal bleeding and to develop a high-accuracy prediction tool. The analysis included 8254 cases of acute hematochezia patients who were admitted urgently based on the judgment of emergency physicians or gastroenterology consultants (from the CODE BLUE J-study). Patients were randomly assigned to a derivation cohort and a validation cohort in a 2:1 ratio using a random number table. Assuming that factors present at the time of admission are involved in mortality within 30 days of admission, and adding management factors during hospitalization to the factors at the time of admission for mortality within 1 year, prognostic factors were established. Multivariate analysis was conducted, and scores were assigned to each factor using regression coefficients, summing these to measure the score. The newly created score (CACHEXIA score) became a tool capable of measuring both mortality within 30 days (ROC-AUC 0.93) and within 1 year (C-index, 0.88). The 1-year mortality rates for patients classified as low, medium, and high risk by the CACHEXIA score were 1.0%, 13.4%, and 54.3% respectively (all P < 0.001). After discharge, patients identified as high risk using our unique predictive score require ongoing observation.

The Japanese Urological Association's clinical practice guidelines for urotrauma 2023

The Japanese Urological Association's guidelines for the treatment of renal trauma were published in 2016. In conjunction with its revision, herein, we present the new guidelines for overall urotrauma. Its purpose is to provide standard diagnostic and treatment recommendations for urotrauma, including iatrogenic trauma, to preserve organ function and minimize complications and fatality. The guidelines committee comprised urologists with experience in urotrauma care, selected by the Trauma and Emergency Medicine Subcommittee of the Specialty Area Committee of the Japanese Urological Association, and specialists recommended by the Japanese Association for the Surgery of Trauma and the Japanese Society of Interventional Radiology. The guidelines committee established the domains of renal and ureteral, bladder, urethral, and genital trauma, and determined the lead person for each domain. A total of 30 clinical questions (CQs) were established for all domains; 15 for renal and ureteral trauma and five each for the other domains. An extensive literature search was conducted for studies published between January 1, 1983 and July 16, 2020, based on the preset keywords for each CQ. Since only few randomized controlled trials or meta-analyses were found on urotrauma clinical practice, conducting a systematic review and summarizing the evidence proved challenging; hence, the grade of recommendation was determined according to the 2007 "Minds Handbook for Clinical Practice Guidelines" based on a consensus reached by the guidelines committee. We hope that these guidelines will be useful for clinicians in their daily practice, especially those involved in urotrauma care.

Impact of resuscitative endovascular balloon occlusion of the aorta on gastrointestinal function with a matched cohort study

Background

Resuscitative endovascular balloon occlusion of the aorta (REBOA) can temporarily control arterial hemorrhage in torso trauma; however, the abdominal visceral blood flow is also blocked by REBOA. The aim of this study was to evaluate the influence of REBOA on gastrointestinal function.

Methods

A retrospective review identified all trauma patients admitted to our trauma center between 2008 and 2019. We used propensity score matching analysis to compare the gastrointestinal function between subjects who underwent REBOA and those who did not. Data on demographics, feeding intolerance (FI), time to feeding goal achievement, and complications were retrieved.

Results

During the study period, 55 patients underwent REBOA. A total of 1694 patients met the inclusion criteria, 27 of whom were a subset of those who underwent REBOA. After 1:1 propensity score matching, the REBOA and no-REBOA groups were assigned 22 patients each. Patients in the REBOA group had a significantly higher incidence of FI (77% vs. 27%; OR, 9.1; 95% CI, 2.31 to 35.7; p=0.002) and longer time to feeding goal achievement (8 vs. 6 days, p=0.022) than patients in the no-REBOA group. Patients in the REBOA group also showed significantly prolonged durations of ventilator use (8 vs. 4 days, p=0.023). Furthermore, there was no difference in the mortality rate between the groups (9% vs. 9%, p=1.000).

Conclusions

REBOA was associated with gastrointestinal dysfunction. Our study findings can be useful in providing guidance on managing nutrition in trauma patients who undergo REBOA.

Level of evidence

Level IV.

Study type

Care management.

Characteristics, outcomes, and risk factors of surgery for acute lower gastrointestinal bleeding: nationwide cohort study of 10,342 hematochezia cases

BACKGROUND

Current evidence on the surgical rate, indication, procedure, risk factors, mortality, and postoperative rebleeding for acute lower gastrointestinal bleeding (ALGIB) is limited.

METHODS

We constructed a retrospective cohort of 10,342 patients admitted for acute hematochezia at 49 hospitals (CODE BLUE J-Study) and evaluated clinical data on the surgeries performed.

RESULTS

Surgery was performed in 1.3% (136/10342) of the cohort with high rates of colonoscopy (87.7%) and endoscopic hemostasis (26.7%). Indications for surgery included colonic diverticular bleeding (24%), colorectal cancer (22%), and small bowel bleeding (16%). Sixty-four percent of surgeries were for hemostasis for severe refractory bleeding. Postoperative rebleeding rates were 22% in patients with presumptive or obscure preoperative identification of the bleeding source and 12% in those with definitive identification. Thirty-day mortality rates were 1.5% and 0.8% in patients with and without surgery, respectively. Multivariate analysis showed that surgery-related risk factors were transfusion need ≥ 6 units (P < 0.001), in-hospital rebleeding (P < 0.001), small bowel bleeding (P < 0.001), colorectal cancer (P < 0.001), and hemorrhoids (P < 0.001). Endoscopic hemostasis was negatively associated with surgery (P = 0.003). For small bowel bleeding, the surgery rate was significantly lower in patients with endoscopic hemostasis as 2% compared to 12% without endoscopic hemostasis.

CONCLUSIONS

Our cohort study elucidated the outcomes and risks of the surgery. Extensive exploration including the small bowel to identify the source of bleeding and endoscopic hemostasis may reduce unnecessary surgery and improve the management of ALGIB.

Long-term Risks of Recurrence After Hospital Discharge for Acute Lower Gastrointestinal Bleeding: A Large Nationwide Cohort Study

BACKGROUND & AIMS

Currently, large, nationwide, long-term follow-up data on acute lower gastrointestinal bleeding (ALGIB) are scarce. We investigated long-term risks of recurrence after hospital discharge for ALGIB using a large multicenter dataset.

METHODS

We retrospectively analyzed 5048 patients who were urgently hospitalized for ALGIB at 49 hospitals across Japan (CODE BLUE-J study). Risk factors for the long-term recurrence of ALGIB were analyzed by using competing risk analysis, treating death without rebleeding as a competing risk.

RESULTS

Rebleeding occurred in 1304 patients (25.8%) during a mean follow-up period of 31 months. The cumulative incidences of rebleeding at 1 and 5 years were 15.1% and 25.1%, respectively. The mortality risk was significantly higher in patients with out-of-hospital rebleeding episodes than in those without (hazard ratio, 1.42). Of the 30 factors, multivariate analysis showed that shock index ≥1 (subdistribution hazard ratio [SHR], 1.25), blood transfusion (SHR, 1.26), in-hospital rebleeding (SHR, 1.26), colonic diverticular bleeding (SHR, 2.38), and thienopyridine use (SHR, 1.24) were significantly associated with increased rebleeding risk. Multivariate analysis of colonic diverticular bleeding patients showed that blood transfusion (SHR, 1.20), in-hospital rebleeding (SHR, 1.30), and thienopyridine use (SHR, 1.32) were significantly associated with increased rebleeding risk, whereas endoscopic hemostasis (SHR, 0.83) significantly decreased the risk.

CONCLUSIONS

These large, nationwide follow-up data highlighted the importance of endoscopic diagnosis and treatment during hospitalization and the assessment of the need for ongoing thienopyridine use to reduce the risk of out-of-hospital rebleeding. This information also aids in the identification of patients at high risk of rebleeding.

Early feeding reduces length of hospital stay in patients with acute lower gastrointestinal bleeding: A large multicentre cohort study

AIM

No studies have compared the clinical outcomes of early and delayed feeding in patients with acute lower gastrointestinal bleeding (ALGIB). This study aimed to evaluate the benefits and risks of early feeding in a nationwide cohort of patients with ALGIB in whom haemostasis was achieved.

METHODS

We reviewed data for 5910 patients with ALGIB in whom haemostasis was achieved and feeding was resumed within 3 days after colonoscopy at 49 hospitals across Japan (CODE BLUE-J Study). Patients were divided into an early feeding group (≤1 day, n = 3324) and a delayed feeding group (2-3 days, n = 2586). Clinical outcomes were compared between the groups by propensity matching analysis of 1508 pairs.

RESULTS

There was no significant difference between the early and delayed feeding groups in the rebleeding rate within 7 days after colonoscopy (9.4% vs. 8.0%; p = 0.196) or in the rebleeding rate within 30 days (11.4% vs. 11.5%; p = 0.909). There was also no significant between-group difference in the need for interventional radiology or surgery or in mortality. However, the median length of hospital stay after colonoscopy was significantly shorter in the early feeding group (5 vs. 7 days; p < 0.001). These results were unchanged when subgroups of presumptive and definitive colonic diverticular bleeding were compared.

CONCLUSION

The findings of this nationwide study suggest that early feeding after haemostasis can shorten the hospital stay in patients with ALGIB without increasing the risk of rebleeding.

A clinical prediction model for non-operative management failure in patients with high-grade blunt splenic injury

Background

Nonoperative management (NOM) is the standard treatment for hemodynamically stable blunt splenic injury (BSI). However, NOM failure is a significant source of morbidity and mortality. We developed a clinical risk scoring system for NOM failure in BSI.

Methods

Data from the Japanese Trauma Data Bank from 2008 to 2018 were analyzed. Eligible patients were restricted to those who underwent NOM with high-grade BSI (Organ Injury Scale ≥3). The primary outcome was a predictive score for NOM failure based on risk estimation.

Results

There were 1651 patients included in this analysis, among whom 110 (6.7%) patients had NOM failure. Multivariate analysis identified seven variables associated with failed NOM: systolic blood pressure, Glasgow coma scale, Injury Severity Score, other concomitant abdominal injury, pelvic injury, high-grade BSI, and angioembolization. An eight-point predictive score was developed with a cut-off of greater than 5 points (specificity, 98.2%; sensitivity, 25.5%) with an area under the curve of 0.81.

Conclusion

The clinical predictive score had good ability to predict NOM failure and may help surgeons to make better decisions for BSI.

Weekend Effect on Clinical Outcomes of Acute Lower Gastrointestinal Bleeding: A Large Multicenter Cohort Study in Japan

INTRODUCTION

Weekend admissions showed increased mortality in several medical conditions. This study aimed to examine the weekend effect on acute lower gastrointestinal bleeding (ALGIB) and its mortality and other outcomes.

METHODS

This retrospective cohort study (CODE BLUE-J Study) was conducted at 49 Japanese hospitals between January 2010 and December 2019. In total, 8,120 outpatients with acute hematochezia were enrolled and divided into weekend admissions and weekday admissions groups. Multiple imputation (MI) was used to handle missing values, followed by propensity score matching (PSM) to compare outcomes. The primary outcome was mortality; the secondary outcomes were rebleeding, length of stay (LOS), blood transfusion, thromboembolism, endoscopic treatment, the need for interventional radiology, and the need for surgery. Colonoscopy and computed tomography (CT) management were also evaluated.

RESULTS

Before PSM, there was no significant difference in mortality (1.3% vs. 0.9%, p = 0.133) between weekend and weekday admissions. After PSM with MI, 1,976 cases were matched for each admission. Mortality was not significantly different for weekend admissions compared with weekday admissions (odds ratio [OR] 1.437, 95% confidence interval [CI] 0.785-2.630; p = 0.340). No significant difference was found with other secondary outcomes in weekend admissions except for blood transfusion (OR 1.239, 95% CI 1.084-1.417; p = 0.006). Weekend admission had a negative effect on early colonoscopy (OR 0.536, 95% CI 0.471-0.609; p < 0.001). Meanwhile, urgent CT remained significantly higher in weekend admissions (OR 1.466, 95% CI 1.295-1.660; p < 0.001).

CONCLUSION

Weekend admissions decrease early colonoscopy and increase urgent CT but do not affect mortality or other outcomes except transfusion.

Development and validation of a novel model for predicting stigmata of recent hemorrhage in acute lower gastrointestinal bleeding: Multicenter nationwide study

OBJECTIVES

Stigmata of recent hemorrhage (SRH) directly indicate a need for endoscopic therapy in acute lower gastrointestinal bleeding (LGIB). Colonoscopy would be prioritized for patients with highly suspected SRH, but the predictors of colonic SRH remain unclear. We aimed to construct a predictive model for the efficient detection of SRH using a nationwide cohort.

METHODS

We retrospectively analyzed 8360 patients admitted through hospital emergency departments for acute LGIB in the CODE BLUE-J Study (49 hospitals throughout Japan). All patients underwent inpatient colonoscopy. To develop an SRH predictive model, 4863 patients were analyzed. Baseline characteristics, colonoscopic factors (timing, preparation, and devices), and computed tomography (CT) extravasation were extensively assessed. The performance of the model was externally validated in 3497 patients.

RESULTS

Colonic SRH was detected in 28% of patients. A novel predictive model for detecting SRH (CS-NEED score: ColonoScopic factors, No abdominal pain, Elevated PT-INR, Extravasation on CT, and DOAC use) showed high performance (area under the receiver operating characteristic curve [AUC] 0.74 for derivation and 0.73 for external validation). This score was also highly predictive of active bleeding (AUC 0.73 for derivation and 0.76 for external validation). Patients with low (0-6), intermediate (7-8), and high (9-12) scores in the external validation cohort had SRH identification rates of 20%, 31%, and 64%, respectively (P < 0.001 for trend).

CONCLUSIONS

A novel predictive model for colonic SRH identification (CS-NEED score) can specify colonoscopies likely to achieve endoscopic therapy in acute LGIB. Using the model during initial management would contribute to finding and treating SRH efficiently.

LONG-HOSP Score: A Novel Predictive Score for Length of Hospital Stay in Acute Lower Gastrointestinal Bleeding - A Multicenter Nationwide Study

INTRODUCTION

Length of stay (LOS) in hospital affects cost, patient quality of life, and hospital management; however, existing gastrointestinal bleeding models applicable at hospital admission have not focused on LOS. We aimed to construct a predictive model for LOS in acute lower gastrointestinal bleeding (ALGIB).

METHODS

We retrospectively analyzed the records of 8,547 patients emergently hospitalized for ALGIB at 49 hospitals (the CODE BLUE-J Study). A predictive model for prolonged hospital stay was developed using the baseline characteristics of 7,107 patients and externally validated in 1,440 patients. Furthermore, a multivariate analysis assessed the impact of additional variables during hospitalization on LOS.

RESULTS

Focusing on baseline characteristics, a predictive model for prolonged hospital stay was developed, the LONG-HOSP score, which consisted of low body mass index, laboratory data, old age, nondrinker status, nonsteroidal anti-inflammatory drug use, facility with ≥800 beds, heart rate, oral antithrombotic agent use, symptoms, systolic blood pressure, performance status, and past medical history. The score showed relatively high performance in predicting prolonged hospital stay and high hospitalization costs (area under the curve: 0.70 and 0.73 for derivation, respectively, and 0.66 and 0.71 for external validation, respectively). Next, we focused on in-hospital management. Diagnosis of colitis or colorectal cancer, rebleeding, and the need for blood transfusion, interventional radiology, and surgery prolonged LOS, regardless of the LONG-HOSP score. By contrast, early colonoscopy and endoscopic treatment shortened LOS.

CONCLUSIONS

At hospital admission for ALGIB, our novel predictive model stratified patients by their risk of prolonged hospital stay. During hospitalization, early colonoscopy and endoscopic treatment shortened LOS.

Outcomes and recurrent bleeding risks of detachable snare and band ligation for colonic diverticular bleeding: a multicenter retrospective cohort study

BACKGROUND AND AIMS

Ligation therapy, including endoscopic detachable snare ligation (EDSL) and endoscopic band ligation (EBL), has emerged as an endoscopic treatment for colonic diverticular bleeding (CDB); its comparative effectiveness and risk of recurrent bleeding remain unclear, however. Our goal was to compare the outcomes of EDSL and EBL in treating CDB and identify risk factors for recurrent bleeding after ligation therapy.

METHODS

We reviewed data of 518 patients with CDB who underwent EDSL (n = 77) or EBL (n = 441) in a multicenter cohort study named the Colonic Diverticular Bleeding Leaders Update Evidence From Multicenter Japanese Study (CODE BLUE-J Study). Outcomes were compared by using propensity score matching. Logistic and Cox regression analyses were performed for recurrent bleeding risk, and a competing risk analysis was used to treat death without recurrent bleeding as a competing risk.

RESULTS

No significant differences were found between the 2 groups in terms of initial hemostasis, 30-day recurrent bleeding, interventional radiology or surgery requirements, 30-day mortality, blood transfusion volume, length of hospital stay, and adverse events. Sigmoid colon involvement was an independent risk factor for 30-day recurrent bleeding (odds ratio, 1.87; 95% confidence interval, 1.02-3.40; P = .042). History of acute lower GI bleeding (ALGIB) was a significant long-term recurrent bleeding risk factor on Cox regression analysis. A performance status score of 3/4 and history of ALGIB were long-term recurrent bleeding factors on competing risk regression analysis.

CONCLUSIONS

There were no significant differences in outcomes between EDSL and EBL for CDB. After ligation therapy, careful follow-up is required, especially in the treatment of sigmoid diverticular bleeding during admission. History of ALGIB and performance status at admission are important risk factors for long-term recurrent bleeding after discharge.

Multicenter propensity score-matched analysis comparing short versus long cap-assisted colonoscopy for acute hematochezia

Background and Aim

While short and long attachment caps are available for colonoscopy, it is unclear which type is more appropriate for stigmata of recent hemorrhage (SRH) identification in acute hematochezia. This study aimed to compare the performance of short versus long caps in acute hematochezia diagnoses and outcomes.

Methods

We selected 6460 patients who underwent colonoscopy with attachment caps from 10 342 acute hematochezia cases in the CODE BLUE-J study. We performed propensity score matching (PSM) to balance baseline characteristics between short and long cap users. Then, the proportion of definitive or presumptive bleeding etiologies found on the initial colonoscopy and SRH identification rates were compared. We also evaluated rates of blood transfusions, interventional radiology, or surgery, as well as the rate of rebleeding and mortality within 30 days after the initial colonoscopy.

Results

A total of 3098 patients with acute hematochezia (1549 short cap and 1549 long cap users) were selected for PSM. The rate of colonic diverticular bleeding (CDB) diagnosis was significantly higher in long cap users (P = 0.006). While the two groups had similar rates of the other bleeding etiologies, the frequency of unknown etiologies was significantly lower in long cap users (P < 0.001). The rate of SRH with active bleeding was significantly higher in long cap users (P < 0.001). Other clinical outcomes did not differ significantly.

Conclusion

Compared to that with short caps, long cap-assisted colonoscopy is superior for the diagnosis of acute hematochezia, especially CDB, and the identification of active bleeding.

Immediate CT after hospital arrival and decreased in-hospital mortality in severely injured trauma patients

BACKGROUND

Immediate whole-body CT (about 10 min after arrival) in an all-in-one resuscitation room equipped with CT has been found to be associated with shorter time to haemostasis and lower in-hospital mortality. The aim of this study was to elucidate the benefits of immediate whole-body CT after hospital arrival in patients with severe trauma with the hypothesis that immediate CT within 10 min is associated with lower in-hospital mortality.

METHOD

This retrospective cohort study of patients with an injury severity score of more than 15 who underwent whole-body CT was conducted using the Japanese Trauma Databank (2019-2020). An immediate CT was conducted within 10 min after arrival. In-hospital mortality, frequency of subsequent surgery, and time to surgery were compared with immediate and non-immediate CT. Inverse probability weighting was conducted to adjust for patient backgrounds, including mechanism and severity of injury, prehospital treatment, vital signs, and institutional characteristics.

RESULTS

Among the 7832 patients included, 646 underwent immediate CT. Immediate CT was associated with lower in-hospital mortality (12.5 versus 15.7 per cent; adjusted OR 0.77 (95 per cent c.i. 0.69 to 0.84); P < 0.001) and fewer damage-control surgeries (OR 0.75 (95 per cent c.i. 0.65 to 0.87)). There was a 10 to 20 min difference in median time to craniotomy, laparotomy, and angiography. These benefits were observed regardless of haemodynamic instability on hospital arrival, while they were identified only in elderly patients with severe injury and altered consciousness.

CONCLUSION

Immediate CT within 10 min after arrival was associated with decreased in-hospital mortality in severely injured trauma patients.

Timing of colonoscopy in acute lower GI bleeding: a multicenter retrospective cohort study

BACKGROUND AND AIMS

We aimed to determine the optimal timing of colonoscopy and factors that benefit patients who undergo early colonoscopy for acute lower GI bleeding.

METHODS

We identified 10,342 patients with acute hematochezia (CODE BLUE-J study) admitted to 49 hospitals in Japan. Of these, 6270 patients who underwent a colonoscopy within 120 hours were included in this study. The inverse probability of treatment weighting method was used to adjust for baseline characteristics among early (≤24 hours, n = 4133), elective (24-48 hours, n = 1137), and late (48-120 hours, n = 1000) colonoscopy. The average treatment effect was evaluated for outcomes. The primary outcome was 30-day rebleeding rate.

RESULTS

The early group had a significantly higher rate of stigmata of recent hemorrhage (SRH) identification and a shorter length of stay than the elective and late groups. However, the 30-day rebleeding rate was significantly higher in the early group than in the elective and late groups. Interventional radiology (IVR) or surgery requirement and 30-day mortality did not significantly differ among groups. The interaction with heterogeneity of effects was observed between early and late colonoscopy and shock index (shock index <1, odds ratio [OR], 2.097; shock index ≥1, OR, 1.095; P for interaction = .038) and performance status (0-2, OR, 2.481; ≥3, OR, .458; P for interaction = .022) for 30-day rebleeding. Early colonoscopy had a significantly lower IVR or surgery requirement in the shock index ≥1 cohort (OR, .267; 95% confidence interval, .099-.721) compared with late colonoscopy.

CONCLUSIONS

Early colonoscopy increased the rate of SRH identification and shortened the length of stay but involved an increased risk of rebleeding and did not improve mortality and IVR or surgery requirement. Early colonoscopy particularly benefited patients with a shock index ≥1 or performance status ≥3 at presentation.

Hypotension at Hospital Presentation and Post-Contrast Acute Kidney Injury following Computed Tomography with Contrast Media

INTRODUCTION

Post-contrast acute kidney injury (PC-AKI) is a major complication of contrast media usage; risks for PC-AKI are generally evaluated before computed tomography (CT) with contrast at the emergency department (ED). Although persistent hypotension (systolic blood pressure [sBP] <80 mm Hg for 1 h) is associated with increased PC-AKI incidence, it remains unclear whether transient hypotension that is haemodynamically stabilized before CT is a risk of PC-AKI. We hypothesized that hypotension on ED arrival would be associated with higher PC-AKI incidence even if CT with contrast was performed after patients are appropriately resuscitated.

METHODS

This multicentre retrospective observational study was conducted at three tertiary care centres during 2013-2014. We identified 280 patients who underwent CT with contrast at the ED. Patients were classified into two groups based on sBP on arrival (<80 vs. ≥80 mm Hg); hypotension was considered as transient because CT with contrast has always been performed after patients were stabilized at participating hospitals. PC-AKI incidence was compared between the groups; inverse probability weighting (IPW) was conducted to adjust background characteristics.

RESULTS

Eighteen patients were excluded due to chronic haemodialysis, cardiac arrest on arrival, or death within 72 h; 262 were eligible for this study. PC-AKI incidence was higher in the transient hypotension group than the normotension group {7/27 (28.6%) vs. 24/235 (10.2%), odds ratio (OR) 3.08 (95% confidence interval [CI] 1.18-8.03), p = 0.026}, which was confirmed by IPW (OR 3.25 [95% CI 1.99-5.29], p < 0.001).

CONCLUSION

Transient hypotension at the ED was associated with PC-AKI development.

Treatment strategies for reducing early and late recurrence of colonic diverticular bleeding based on stigmata of recent hemorrhage: a large multicenter study

BACKGROUND AND AIMS

Treatment strategies for colonic diverticular bleeding (CDB) based on stigmata of recent hemorrhage (SRH) remain unstandardized, and no large studies have evaluated their effectiveness. We sought to identify the best strategy among combinations of SRH identification and endoscopic treatment strategies.

METHODS

We retrospectively analyzed 5823 CDB patients who underwent colonoscopy at 49 hospitals throughout Japan (CODE-BLUE J-Study). Three strategies were compared: find SRH (definitive CDB) and treat endoscopically, find SRH (definitive CDB) and treat conservatively, and without finding SRH (presumptive CDB) treat conservatively. In conducting pairwise comparisons of outcomes in these groups, we used propensity score-matching analysis to balance baseline characteristics between the groups being compared.

RESULTS

Both early and late recurrent bleeding rates were significantly lower in patients with definitive CDB treated endoscopically than in those with presumptive CDB treated conservatively (<30 days, 19.6% vs 26.0% [P < .001]; <365 days, 33.7% vs 41.6% [P < .001], respectively). In patients with definitive CDB, the early recurrent bleeding rate was significantly lower in those treated endoscopically than in those treated conservatively (17.4% vs 26.7% [P = .038] for a single test of hypothesis; however, correction for multiple testing of data removed this significance). The late recurrent bleeding rate was also lower, but not significantly, in those treated endoscopically (32.0% vs 36.1%, P = .426). Definitive CDB treated endoscopically showed significantly lower early and late recurrent bleeding rates than when treated conservatively in cases of SRH with active bleeding, nonactive bleeding, and in the right-sided colon but not left-sided colon.

CONCLUSIONS

Treating definitive CDB endoscopically was most effective in reducing recurrent bleeding over the short and long term, compared with not treating definitive CDB or presumptive CDB. Physicians should endeavor to find and treat SRH for suspected CDB.

Trends in Aortic Occlusion and How to Minimize the Risk of Complications in REBOA

Resuscitative endovascular balloon occlusion of the aorta (REBOA) increases proximal aortic pressure in order to maintain central organ perfusion pressure, and simultaneously regulates distal arterial flow by endovascular aortic occlusion, which is applied during subdiaphragmatic hemorrhage. This article briefly introduces the history of REBOA and discusses its potential effectiveness and harmfulness. The following sections mention the technical aspects of REBOA, and reconsider the term “REBOA” and “resuscitation.” The risks of aortic occlusion and ischemia-reperfusion injury have not been fully elucidated. The authors hope that REBOA can be used appropriately as a powerful option for the resuscitation of hemorrhagic patients and save the lives of as many patients as possible. The Japanese Society of Diagnostic and Interventional Radiology in Emergency, Critical Care, and Trauma will publish continuous medical education articles on REBOA as narrative review articles.

Endoscopic direct clipping versus indirect clipping for colonic diverticular bleeding: A large multicenter cohort study

BACKGROUND

Direct and indirect clipping treatments are used worldwide to treat colonic diverticular bleeding (CDB), but their effectiveness has not been examined in multicenter studies with more than 100 cases.

OBJECTIVE

We sought to determine the short- and long-term effectiveness of direct versus indirect clipping for CDB in a nationwide cohort.

METHODS

We studied 1041 patients with CDB who underwent direct clipping (n = 360) or indirect clipping (n = 681) at 49 hospitals across Japan (CODE BLUE-J Study).

RESULTS

Multivariate analysis adjusted for age, sex, and important confounding factors revealed that, compared with indirect clipping, direct clipping was independently associated with reduced risk of early rebleeding (<30 days; adjusted odds ratio [AOR] 0.592, p = 0.002), late rebleeding (<1 year; AOR 0.707, p = 0.018), and blood transfusion requirement (AOR 0.741, p = 0.047). No significant difference in initial hemostasis rates was observed between the two groups. Propensity-score matching to balance baseline characteristics also showed significant reductions in the early and late rebleeding rates with direct clipping. In subgroup analysis, direct clipping was associated with significantly lower rates of early and late rebleeding and blood transfusion need in cases of stigmata of recent hemorrhage with non-active bleeding on colonoscopy, right-sided diverticula, and early colonoscopy, but not with active bleeding on colonoscopy, left-sided diverticula, or elective colonoscopy.

CONCLUSIONS

Our large nationwide study highlights the use of direct clipping for CDB treatment whenever possible. Differences in bleeding pattern and colonic location can also be considered when deciding which clipping options to use.

Factors associated with prolonged procedure time of embolization for trauma patients

Aim

Limited information exists on the factors associated with prolonged procedural time in embolization for trauma patients. We clarified the clinical application of embolization in trauma patients and factors associated with a prolonged procedure time.

Methods

Medical records of 162 trauma patients who underwent embolization between January 2007 and December 2020 at a regional trauma care center were reviewed retrospectively. Patients were divided into four embolized body regions: chest, abdomen, pelvis, and other. Patient demographics, trauma mechanism, physiology, trauma severity, embolization procedures, and 30‐day mortality were examined. The outcomes were identifying an embolized body region, embolized arteries, and procedure time. Multiple regression model was created to investigate the factors associated with prolonged procedural time in embolization.

Results

Embolization was mainly undertaken in pelvic fractures (n = 96, 59%) and abdominal organ injuries (n = 57, 35%) and extended to the chest (n = 17, 10%), and other (n = 20, 12%). Approximately 13% (n = 21) of patients underwent embolization in two or more regions. Embolization was more strictly performed in minor artery injuries, for example, external iliac (n = 15, 16%) and lumbar artery (n = 22, 23%) branches in pelvic fractures, and inferior phrenic artery (n = 2, 3.5%) branches in liver injuries. Multiple regression model indicated that the number of embolized arteries (P = 0.021) and number of embolized regions (P < 0.001) were associated with prolonged procedural time in embolization.

Conclusions

Embolization for trauma patients extended to various trauma regions. In time‐sensitive embolization, emergency interventional radiologists showed superior knowledge of expected embolizing arteries and factors associated with procedure time.

Difference in postcourse knowledge and confidence between Web-based and on-site training courses on resuscitative endovascular balloon occlusion of the aorta

Aim

Effective courses are essential for highly invasive procedures such as resuscitative endovascular balloon occlusion of the aorta. However, the coronavirus disease pandemic has forced the postponement of on‐site educational courses due to transmission concerns. Few studies have examined the effectiveness of Web‐based education in highly invasive procedures. To address this knowledge gap, this study aimed to investigate whether knowledge acquisition and confidence after the Web‐based course are different from those acquired after the on‐site course, using pre‐ and postcourse test scores.

Methods

The increase in scores before and after the course was compared between the on‐site and Web‐based courses. The questions reflected knowledge about seven different topics in the course modules. In addition, participants were asked about their self‐rated confidence about three topics before and after the course.

Results

Thirty learners completed the on‐site course, and 21 learners completed the Web‐based course. Forty‐seven learners completed both the precourse and postcourse tests. In both courses, the difference between the precourse and postcourse test scores showed a statistically significant increase in knowledge (on‐site course: increased score, 1.8; 95% confidence interval, 0.8 to 2.8; Web‐based course: increased score, 1.6, 95% confidence interval, 0.5 to 2.5). However, the difference was not statistically significant in the self‐rated confidence scores about “sheath and catheter removal” among learners of the Web‐based course.

Conclusion

Knowledge increased significantly in both the on‐site and Web‐based courses. However, the Web‐based course might not be sufficient to give learners confidence in the procedures.

Outcomes in high and low volume hospitals in patients with acute hematochezia in a cohort study

Outcomes of acute lower gastrointestinal bleeding have not been compared according to hospital capacity. We aimed to perform a propensity score-matched cohort study with path and mediation analyses for acute hematochezia patients. Hospitals were divided into high- versus low-volume hospitals for emergency medical services. Rebleeding and death within 30 days were compared. Computed tomography, early colonoscopy (colonoscopy performed within 24 h), and endoscopic therapies were included as mediators. A total of 2644 matched pairs were yielded. The rebleeding rate within 30 days was not significant between high- and low-volume hospitals (16% vs. 17%, P = 0.44). The mortality rate within 30 days was significantly higher in the high-volume cohort than in the low-volume cohort (1.7% vs. 0.8%, P = 0.003). Treatment at high-volume hospitals was not a significant factor for rebleeding (odds ratio [OR] = 0.91; 95% confidence interval [CI], 0.79-1.06; P = 0.23), but was significant for death within 30 days (OR = 2.03; 95% CI, 1.17-3.52; P = 0.012) on multivariate logistic regression after adjusting for patients' characteristics. Mediation effects were not observed, except for rebleeding within 30 days in high-volume hospitals through early colonoscopy. However, the direct effect of high-volume hospitals on rebleeding was not significant. High-volume hospitals did not improve the outcomes of acute hematochezia patients.

Hybrid trauma service: on the leading edge of damage Control

Trauma damage control seeks to limit life-threatening bleeding. Sequential diagnostic and therapeutic approaches are the current standard. Hybrid Room have reduced hemostasis time by integrating different specialties and technologies. Hybrid Rooms seek to control bleeding in an operating room equipped with specialized personnel and advanced technology including angiography, tomography, eFAST, radiography, endoscopy, infusers, cell retrievers, REBOA, etc. Trauma Hybrid Service is a concept that describes a vertical work scheme that begins with the activation of Trauma Code when admitting a severely injured patient, initiating a continuous resuscitation process led by the trauma surgeon who guides transfer to imaging, angiography and surgery rooms according to the patient's condition and the need for specific interventions. Hybrid rooms integrate different diagnostic and therapeutic tools in one same room, reducing the attention time and increasing all interventions effectiveness.

Effectiveness and Usage Trends of Hemorrhage Control Interventions in Patients with Pelvic Fracture in Shock

BACKGROUND

Hemorrhage control for pelvic fractures remains challenging. There are several kinds of hemostatic interventions, including angiography/angioembolization (AG/AE), external fixation (EF), and resuscitative endovascular balloon occlusion of the aorta (REBOA). However, no large studies have been conducted for the comparative review of each intervention. In this study, we examined the usage trend of therapeutic interventions in Japan for patients with pelvic fractures in shock and the influence of these interventions on mortality.

METHODS

Data of adult patients with pelvic fracture who were in shock were obtained from the Japanese Trauma Data Bank (2004-2014). The primary endpoint was the influence of each intervention (AG/AE, EF, and REBOA) on in-hospital mortality. We also investigated the frequency of each intervention.

RESULTS

A total of 3149 patients met all our inclusion criteria. Specifically, 1131 (35.9%), 496 (15.8%), and 256 (8.1%) patients underwent AG, EF, and REBOA interventions, respectively. Therapeutic AE was performed in 690 patients who underwent AG (61.0%). The overall mortality rate was 31.4%. Multiple regression analysis identified that AG/AE (OR 0.64, 95% CI 0.52-0.80) and EF (OR 0.75, 95% CI 0.58-0.98) were significantly associated with survival, whereas REBOA (OR 4.17, 95% CI 3.00-5.82) was significantly associated with worse outcomes.

CONCLUSIONS

In Japan, patients with pelvic fracture who were in shock had high mortality rates. AG/AE and EF were associated with decreased mortality. AG may benefit from the early detection of arterial bleeding, leading to decreased mortality of patients with pelvic fracture in shock.

Hybrid emergency room management of a ruptured abdominal aortic aneurysm

Patients with a ruptured abdominal aortic aneurysm (rAAA) still have high mortality. Rapid diagnosis and treatment are vital for improving survival outcomes. rAAA management has evolved regarding these factors. We have reported the case of a 70-year-old man with an rAAA that was rapidly diagnosed and treated in a hybrid emergency room (ER). A hybrid ER is an integrated ER capable of computed tomography scanning, interventional radiology, and surgery in one place. In the present case, the door-to-intervention time was 35 minutes. The use of hybrid ERs has the potential to enhance the speed and quality of diagnostic and definitive treatment of rAAAs.

Near-fatal negative pressure pulmonary oedema successfully treated with venovenous extracorporeal membrane oxygenation performed in the hybrid emergency room

We report a rare case of negative pressure pulmonary oedema (NPPE), a life-threatening complication of tracheal intubation. A 41-year-old obese man was admitted to a previous hospital for neck surgery. After extubation, he developed respiratory distress followed by haemoptysis and desaturation. The patient was reintubated and brought to our hospital where we introduced venovenous extracorporeal membrane oxygenation (ECMO) to prevent cardiac arrest, which is an unusual clinical course for NPPE. He returned to his routine without any sequelae. This is the first case report of NPPE successfully resolved with venovenous ECMO in the hybrid emergency room (hybrid ER), which is a resuscitation room equipped with interventional radiology features and a sliding CT scanner. Since the hybrid ER serves as a single move for patients where all necessary procedures are performed, it has the potential to lower the incidence of cannulation complications, beyond the delay in ECMO initiation.

Comparison of the Clinical Course of COVID-19 Pneumonia and Acute Respiratory Distress Syndrome in 2 Passengers from the Cruise Ship Diamond Princess in February 2020

BACKGROUND Patients with coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 can rapidly progress to acute respiratory distress syndrome (ARDS). Because clinical diagnosis of ARDS includes several diseases, understanding the characteristics of COVID-19-related ARDS is necessary for precise treatment. We report 2 patients with ARDS due to COVID-19-associated pneumonia. CASE REPORT Case 1 involved a 72-year-old Japanese man who presented with respiratory distress and fever. Computed tomography (CT) revealed subpleural ground-glass opacities (GGOs) and consolidation. Six days after symptom onset, reverse transcription-polymerase chain reaction (RT-PCR) testing confirmed the diagnosis of COVID-19-associated pneumonia. He was intubated and received veno-venous extracorporeal membrane oxygenation (ECMO) 8 days after symptom onset. Follow-up CT revealed large diffuse areas with a crazy-paving pattern and consolidation, which indicated progression of COVID-19-associated pneumonia. Following treatment with antiviral medications and supportive measures, the patient was weaned off ECMO after 20 days. Case 2 involved a 70-year-old Asian man residing in Canada who presented with cough, malaise, nausea, vomiting, and fever. COVID-19-associated pneumonia was diagnosed based on a positive result from RT-PCR testing. The patient was then transferred to the intensive care unit and intubated 8 days after symptom onset. Follow-up CT showed that while the initial subpleural GGOs had improved, diffuse GGOs appeared, similar to those observed upon diffuse alveolar damage. He was administered systemic steroid therapy for ARDS and extubated after 6 days. CONCLUSIONS Because the pattern of symptom exacerbation in COVID-19-associated pneumonia cases seems inconsistent, individual treatment management, especially the CT-based treatment strategy, is crucial.

Resuscitative endovascular balloon occlusion of the aorta and traumatic out-of-hospital cardiac arrest: A nationwide study

OBJECTIVE

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a less-invasive method for temporary hemostasis compared with cross-clamping the aorta through resuscitative thoracotomy (RT). Although the survival benefits of REBOA remained unclear, pathophysiological benefits were identified in patients with traumatic out-of-hospital cardiac arrest (t-OHCA). We examined the clinical outcomes of t-OHCA with the hypothesis that REBOA would be associated with higher survival to discharge compared with RT.

METHODS

A retrospective cohort study was conducted using the Japan Trauma Data Bank (2004-2019). Adult patients with t-OHCA who had arrived without a palpable pulse and undergone aortic occlusion were included. Patients were divided into REBOA or RT groups, and propensity scores were developed using age, mechanism of injury, presence of signs of life, presence of severe head and/or chest injury, Injury Severity Score, and transportation time. Inverse probability weighting by propensity scores was performed to compare survival to discharge between the 2 groups.

RESULTS

Among 13,247 patients with t-OHCA, 1483 were included in this study. A total of 144 (9.7%) patients were treated with REBOA, and 5 of 144 (3.5%) in the REBOA group and 10 of 1339 (0.7%) in the RT group survived to discharge. The use of REBOA was significantly associated with increased survival to discharge (odds ratio, 4.78; 95% confidence interval, 1.61-14.19), which was confirmed by inverse probability weighting (adjusted odds ratio, 3.73; 95% confidence interval, 1.90-7.32).

CONCLUSIONS

REBOA for t-OHCA was associated with higher survival to discharge. These results should be validated by further research.

Delays in Surgical Intervention and Temporary Hemostasis Using Resuscitative Endovascular Balloon Occlusion of the aorta (REBOA): Influence of Time to Operating Room on Mortality

BACKGROUND

The optimal candidates for resuscitative endovascular balloon occlusion of the aorta (REBOA) remain unclear. We hypothesized that patients who experience delays in surgical intervention would benefit from REBOA.

METHODS

Using the Japan Trauma Databank (2014-2019), patients transferred to the operating room (OR) within 3 h were identified. Patients treated with REBOA were matched with those without REBOA using propensity scores, and further divided based on the transfer time to OR: ≤ 1 h (early), 1-2 h (delayed), and >2 h (significantly-delayed). Survival to discharge was compared.

RESULTS

Among 5258 patients, 310 underwent REBOA. In 223 matched pairs, patients treated with REBOA had improved survival (56.5% vs. 31.8%; p < 0.01), although in-hospital mortality was reduced by REBOA only in the delayed and significantly-delayed subgroups (HR = 0.43 [0.28-0.65] and 0.42 [0.25-0.71]).

CONCLUSIONS

REBOA-treated trauma patients who experience delays in surgical intervention (>1 h) have improved survival.

Placement accuracy of resuscitative endovascular occlusion balloon into the target zone with external measurement

Background

Resuscitative endovascular balloon occlusion of the aorta (REBOA) should be safely placed at zone 1 or 3, depending on the location of the hemorrhage. Ideally, REBOA placement should be confirmed via fluoroscopy, but it is not commonly available for trauma bays. This study aimed to evaluate the accuracy of REBOA placement using the external measurement method in a Japanese trauma center.

Methods

A retrospective review identified all trauma patients who underwent REBOA and were admitted to our trauma center from 2008 to 2018. Patient characteristics, REBOA placement accuracy, and complications according to target zones 1 and 3 were reviewed.

Results

During the study period, 38 patients met our inclusion criteria. The in-hospital mortality rate was 57.9%. REBOA was mainly used for bleeding from the abdominal (44.7%) and pelvic (36.8%) regions. Of these, 30 patients (78.9%) underwent REBOA for target zone 1, and 8 patients (21.1%) underwent REBOA for target zone 3. The proportion of abdominal bleeding source in the target zone 1 group was greater than that in the target zone 3 group (56.7% vs. 0%). Overall, the proportion of REBOA placement was 76.3% in zone 1, 21.1% in zone 2, and 2.6% in zone 3. The total REBOA placement accuracy was 71.1%. At each target zone, the REBOA placement accuracy for target zone 3 was significantly lower than that for target zone 1 (12.5% vs. 86.7%, p<0.001). No significant associations between non-target zone placement and patient characteristics, complications, or mortality were found.

Conclusions

The REBOA placement accuracy for target zone 3 was low, and zone 2 placement accounted for 21.1% of the total, but no complications and mortalities related to non-target zone placement occurred. Further external validation study is warranted.

Level of evidence

Level IV.

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) for Severe Torso Trauma in Japan: A Descriptive Study

BACKGROUND

Resuscitative endovascular balloon occlusion of the aorta (REBOA) has the potential to be an alternative to open aortic cross-clamping (ACC). However, its practical indication remains unknown. We examined the usage trend of REBOA and ACC in Japan for severe torso trauma and investigated whether these procedures were associated with the time of death distribution based on a large database from the Japan Trauma Data Bank (JTDB).

METHODS

The JTDB from 2004 to 2014 was reviewed. Eligible patients were restricted to those with severe torso trauma, which was defined as an abbreviated injury scale score of ≥4. Patients were classified into groups according to the aortic occlusion procedures. The primary outcomes were the rates of REBOA and ACC use according to the clinical situation. We also evaluated whether the time of death distribution for the first 8 h differed based on these procedures.

RESULTS

During the study period, a total of 21,533 patients met our inclusion criteria. Overall, REBOA was more commonly used than ACC for patients with severe torso trauma (2.8% vs 1.5%). However, ACC was more frequently used in cases of thoracic injury and cardiac arrest. Regarding the time of death distribution, the cumulative curve for death in REBOA cases was elevated much more slowly and mostly flat for the first 100 min.

CONCLUSIONS

REBOA is more commonly used compared to ACC for patients with severe torso trauma in Japan. Moreover, it appears that REBOA influences the time of death distribution in the hyperacute phase.

Guidelines for Colonic Diverticular Bleeding and Colonic Diverticulitis: Japan Gastroenterological Association

Colonic diverticular disease has been increasing in prevalence in Japan due to the rapidly aging population. Colonic diverticular bleeding can result in hemorrhagic shock requiring blood transfusion, and it carries a high risk of recurrence within 1 year. Colonic diverticulitis can cause abscess, fistula formation, and perforation of the colon that may require surgery, and it often recurs. As a result, patients with colonic diverticular disease are often bothered by required frequent examinations, re-hospitalization, and a consequent decrease in quality of life. However, the management of diverticular disease differs between Japan and Western countries. For example, computed tomography (CT) is readily accessible at Japanese hospitals, so urgent CT may be selected as the first diagnostic procedure for suspected diverticular disease. Endoscopic clipping or band ligation may be preferred as the first endoscopic procedure for diverticular bleeding. Administration of antibiotics and complete bowel rest may be considered as first-line therapy for colonic diverticulitis. In addition, diverticula occur mainly in the sigmoid colon in Western countries, whereas the right side or bilateral of the colon is more commonly involved in Japan. As such, diverticular disease in the right-side colon is more prevalent in Japan than in Western countries. Against this background, concern is growing about the management of colonic diverticular disease in Japan and there is currently no practice guideline available. To address this situation, the Japanese Gastroenterological Association decided to create a clinical guideline for colonic diverticular bleeding and colonic diverticulitis in collaboration with the Japanese Society of Gastroenterology, Japan Gastroenterological Endoscopy Society, and Japanese Society of Interventional Radiology. The steps taken to establish this guideline involved incorporating the concept of the GRADE system for rating clinical guidelines, developing clinical questions (CQs), accumulating evidence through a literature search and review, and developing the Statement and Explanation sections. This guideline includes 2CQs for colonic diverticulosis, 24 CQs for colonic diverticular bleeding, and 17 CQs for diverticulitis.

Endovascular resuscitation and Trauma Management (EVTM) in the Hybrid Emergency Room System (HERS)

The concept of EndoVascular resuscitation and Trauma Management (EVTM) has recently been proposed to refer to the use of endovascular techniques for resuscitation, haemorrhage control, and definitive trauma management. Although the popularity of resuscitative endovascular balloon occlusion of the aorta (REBOA) has been growing, the use of the EVTM or CT imaging is still limited in hemodynamically unstable patients. To overcome the current limitations, the Hybrid Emergency Room System (HERS) was introduced in 2011. HERS consists of an operating table with an angiographic C-arm and a sliding CT scanner system in the resuscitation area, which allows all emergency diagnostic and therapeutic interventions without relocating the patient. This paper deals with current limitations of EVTM and proposes solutions with HERS. In the HERS environment, patients can undergo IR in the resuscitation room, which may expand the indications of IR to include hemodynamically unstable patients. HERS can also reduce CT scanning time to identify unexpected injuries or traumatic brain injury. It also allows prompt neurosurgical intervention simultaneously with haemorrhage control. REBOA is a viable adjunct treatment for refractory haemorrhagic shock but its procedure-related complications must be considered. REBOA can be performed more safely, rapidly, and accurately in HERS, followed by immediate definitive haemostasis. In addition, HERS may safely extend the application of REBOA-CT to identify accurate injury site. HERS may be an ideal EVTM solution for the trinity of surgery, endovascular treatment, and imaging in trauma care. We will continue to explore the most radical and safest EVTM in the HERS environment.

A Rare Surgical Case of Giant Jejunal Artery Aneurysm in a Young Patient

Aneurysms of the abdominal visceral arteries are infrequently encountered. Jejunal artery aneurysm (JAA) is one of the rarest visceral aneurysms, especially in young patients. Endovascular surgery tends to be an effective treatment for visceral artery aneurysms. Here, we report a case of symptomatic JAA with a peripheral dilated vessel in a young patient. However, in consideration of the patient's anatomic suitability and young age, we chose open surgical intervention with intraoperative angiography. Thus, we could resect the aneurysm and the peripheral dilated vessel, preserve the bowel, and leave no devices that could cause further complication. The choice of the most appropriate treatment should depend on aneurysm characteristics and the background of the patient.

Fewer REBOA complications with smaller devices and partial occlusion: evidence from a multicentre registry in Japan

BACKGROUND

Resuscitative endovascular balloon occlusion of the aorta (REBOA) performed by emergency physicians has been gaining acceptance as a less invasive technique than resuscitative thoracotomy.

OBJECTIVE

To evaluate access-related complications and duration of occlusions during REBOA.

METHODS

Patients with haemorrhagic shock requiring REBOA, from 18 hospitals in Japan, included in the DIRECT-IABO Registry were studied. REBOA-related characteristics were compared between non-survivors and survivors at 24 hours. 24-Hour survivors were categorised into groups with small (≤8 Fr), large (≥9 Fr) or unusual sheaths (oversized or multiple) to assess the relationship between the sheath size and complications. Haemodynamic response, occlusion duration and outcomes were compared between groups with partial and complete REBOA.

RESULTS

Between August 2011 and December 2015, 142 adults undergoing REBOA were analysed. REBOA procedures were predominantly (94%) performed by emergency medicine (EM) physicians. The median duration of the small sheath (n=53) was 19 hours compared with 7.5 hours for the larger sheaths (P=0.025). Smaller sheaths were more likely to be removed using external manual compression (96% vs 45%, P<0.001). One case of a common femoral artery thrombus (large group) and two cases of amputation (unusual group) were identified. Partial REBOA was carried out in more cases (n=78) and resulted in a better haemodynamic response than complete REBOA (improvement in haemodynamics, 92% vs 70%, P=0.004; achievement of stability, 78% vs 51%, P=0.007) and allowed longer occlusion duration (median 58 vs 33 min, P=0.041). No statistically significant difference in 24-hour or 30-day survival was found between partial and complete REBOA.

CONCLUSION

In Japan, EM physicians undertake the majority of REBOA procedures. Smaller sheaths appear to have fewer complications despite relatively prolonged placement and require external compression on removal. Although REBOA is a rarely performed procedure, partial REBOA, which may extend the occlusion duration without a reduction in survival, is used more commonly in Japan.

Early diagnosis of hollow viscus injury using intestinal fatty acid-binding protein in blunt trauma patients

A delay in diagnosing hollow viscus injury (HVI) causes an increase in mortality and morbidity. HVI remains a challenge to diagnose, and there is no specific diagnostic biomarker for HVI. We evaluated the utility of intestinal fatty acid-binding protein (I-FABP) in diagnosing HVI in blunt trauma patients. Within a 5-year period, 93 consecutive patients with clinically suspected HVI at our trauma center were prospectively enrolled. The diagnostic performance of I-FABP for HVI was compared with that of other various parameters (physical, laboratory, and radiographic findings). HVI was diagnosed in 13 patients (14%), and non-HVI was diagnosed in 80 patients (86%). The level of I-FABP was significantly higher in patients with HVI than in those with non-HVI (P = 0.014; area under the curve, 0.71). The sensitivity, specificity, positive predictive value, and negative predictive value were 76.9%, 70.0%, 29.4%, and 94.9%, respectively (P = 0.003). However, all other biomarkers were not significantly different between the groups. Presence of extraluminal air, bowel wall thickening on computed tomography (CT), and peritonitis signs were significantly higher in patients with HVI (P < 0.05). Of 49 patients (52.7%) who had a negative I-FABP and negative peritonitis signs, none developed HVI (sensitivity, 100%; negative predictive value, 100%). This is the first study that demonstrated the diagnostic value of a biomarker for HVI. I-FABP has a higher negative predictive value compared to traditional diagnostic tests. Although the accuracy of I-FABP alone was insufficient, the combination of I-FABP and other findings can enhance diagnostic ability.

Diagnostic value of intestinal fatty acid-binding protein for pneumatosis intestinalis

BACKGROUND

Pneumatosis intestinalis (PI) is known as a sign of a life-threatening bowel ischemia. We aimed to evaluate the utility of intestinal fatty acid-binding protein (I-FABP) in the diagnosis of pathologic PI.

METHODS

All consecutive patients who presented to our emergency department with PI were prospectively enrolled. The diagnostic performance of I-FABP for pathologic PI was compared with that of other traditional biomarkers and various parameters.

RESULTS

Seventy patients with PI were enrolled. Pathologic PI was diagnosed in 27 patients (39%). The levels of most biomarkers were significantly higher in patients with pathologic PI than those with nonpathologic PI (P < .05). Receiver operator characteristic analysis revealed that the area under the curve (AUC) was highest for I-FABP (area under the curve = .82) in the diagnosis of pathologic PI.

CONCLUSIONS

High I-FABP value, in combination with other parameters, might be clinically useful for pathologic PI.

Diagnostic accuracy of oblique chest radiograph for occult pneumothorax: comparison with ultrasonography

Backgraound

An occult pneumothorax is a pneumothorax that is not seen on a supine chest X-ray but is detected by computed tomography scanning. However, critical patients are difficult to transport to the computed tomography suite. We previously reported a method to detect occult pneumothorax using oblique chest radiography (OXR). Several authors have also reported that ultrasonography is an effective technique for detecting occult pneumothorax. The aim of this study was to evaluate the usefulness of OXR in the diagnosis of the occult pneumothorax and to compare OXR with ultrasonography.

Methods

All consecutive blunt chest trauma patients with clinically suspected pneumothorax on arrival at the emergency department were prospectively included at our tertiary-care center. The patients underwent OXR and ultrasonography, and underwent computed tomography scans as the gold standard. Occult pneumothorax size on computed tomography was classified as minuscule, anterior, or anterolateral.

Results

One hundred and fifty-nine patients were enrolled. Of the 70 occult pneumothoraces found in the 318 thoraces, 19 were minuscule, 32 were anterior, and 19 were anterolateral. The sensitivity and specificity of OXR for detecting occult pneumothorax was 61.4 % and 99.2 %, respectively. The sensitivity and specificity of lung ultrasonography was 62.9 % and 98.8 %, respectively. Among 27 occult pneumothoraces that could not be detected by OXR, 16 were minuscule and 21 could be conservatively managed without thoracostomy.

Conclusion

OXR appears to be as good method as lung ultrasonography in the detection of large occult pneumothorax. In trauma patients who are difficult to transfer to computed tomography scan, OXR may be effective at detecting occult pneumothorax with a risk of progression.

Digital video recording in trauma surgery using commercially available equipment

INTRODUCTION

Although videos of surgical procedures are useful as an educational tool, the recording of trauma surgeries in emergency situations is difficult. We describe an inexpensive and practical shooting method using a commercially available head-mounted video camera.

METHODS

We used a ContourHD 1080p Helmet Camera (Contour Inc., Seattle, Washington, USA.). This small, self-contained video camera and recording system was originally designed for easy videography of outdoor sports by participants.

RESULTS

We were able to easily make high-quality video recordings of our trauma surgeries, including an emergency room thoracotomy for chest stab wounds and a crush laparotomy for a severe liver injury.

CONCLUSION

There are currently many options for recording surgery in the field, but the recording device and system should be chosen according to the surgical situation. We consider the use of a helmet-mounted, self-contained high-definition video camera-recorder to be an inexpensive, quick, and easy method for recording trauma surgeries.

64-Slice multidetector computed tomography evaluation of gastrointestinal tract perforation site: detectability of direct findings in upper and lower GI tract

OBJECTIVE

To evaluate wall discontinuity, as observed using 64-slice multidetector-row computed tomography (64-MDCT), as a direct finding (DF) indicating the perforation site in patients with gastrointestinal (GI) tract perforations.

METHODS

We retrospectively studied 41 consecutive patients presenting with acute abdomen and exhibiting extraluminal air (EA) on 64-MDCT. Three readers evaluated the distribution of EA, extraluminal faeces, dirty mass, dirty fat sign, extraluminal fluid collection and bowel wall thickening (i.e. conventional findings, CFs) as well as DFs.

RESULTS

Twenty-two cases were surgically or endoscopically confirmed to have upper GI tract perforations, and 19 had lower GI tract perforations. The DFs correctly identified the sites of perforation in 80.5% of patients when 2-mm-thick imaging slices were used. For the detection of upper GI tract perforations, the sensitivity, specificity and accuracy were 95.5%, 94.7% and 95.1% for the DFs and 50.0%, 100% and 73.2% for the CFs, respectively. Significant differences in sensitivity (p < 0.001) and diagnostic accuracy (p < 0.05) were observed between the DFs and CFs for upper GI perforations but not for lower GI tract perforations.

CONCLUSION

DFs of the perforation site by using 64-MDCT were more sensitive and accurate than CFs for the detection of upper GI tract perforations.

Split chimerism after allogeneic bone marrow transplantation in Chediak-Higashi syndrome

Chediak-Higashi Syndrome (CHS) is a hereditary multiorgan disease associated with a lymphoproliferative disorder termed 'accelerated phase' (AP). As AP is often life-threatening, hematopoietic stem cell transplantation has been proposed as the only curative treatment for CHS. Here, we report a 1-year-old Japanese boy with CHS who received an HLA-matched unrelated BMT at the AP stage, which resulted in split chimerism. We evaluated the chimerism status of isolated leukocytes and found that only a limited population of T and NK cells was of donor origin and the majority of these and other hematopoietic cells was of host origin. Clinical outcome was successful, and the patient is currently alive and well, free of AP and serious infections more than 18 months after BMT.

Cardiopulmonary arrest induced by anaphylactoid reaction with contrast media

Anaphylactoid reactions to iodinated contrast media can cause life-threatening events and even death. A 44-year-old woman presented with cardiopulmonary arrest (CPA) immediately following the administration of nonionic iodinated contrast media for an intravenous pyelography. Her cardiac rhythm during CPA was asystole. She was successfully resuscitated by the radiologists supported by paged emergency physicians using the prompt intravenous administration of 1 mg of epinephrine. Neither laryngeal edema nor bronchial spasm was observed during the course of treatment, and she was discharged on the 4th day without any complications. The patient did not have a history of allergy, but had experienced a myocardial infarction and aortitis. She had undergone 11 angiographies and had been taking a beta-adrenergic receptor antagonist. Planned emergency medical backup is advisable to ensure resuscitation in the event of an anaphylactoid reaction to the use of contrast media in-hospital settings.

Epidemiological study of vancomycin-resistant enterococcus isolated from a single medical university hospital in Japan

Since 1998 more than 50 reports have described the isolation of high-level vancomycin-resistant enterococci (VRE) in Japan. Here, we report on our clinical isolates of VRE and an epidemiological study carried out using chemical and genetic techniques. VRE isolates were screened for high resistance to vancomycin (VCM) with a cutoff value of 6 microg/ml and VCM-resistant gene was confirmed by polymerase chain reaction (PCR). The epidemiological studies used pulsed-field gel electrophoresis (PFGE) and plasmid analysis. Six strains of VRE were isolated from six different patients on two wards during a 3-months period. All of the isolates possessed vanA on their plasmid, and the isolates were divided into two similar groups. Furthermore, three different patterns were defined by PFGE. Although all of the asymptomatic carriers were hospitalized for more than 3 months, we were able to prevent an outbreak of VRE in our hospital by using our guidelines for infection control, which are stricter than those for methicillin-resistant Staphylococcus aurens. From the results of this epidemiological study, we propose that there was a possibility of contamination in this hospital, and that three of the six isolates may have acquired vanA independently. In this study, we demonstrated that infection control, according to appropriate prevention guidelines, as well as regular surveillance for VRE, are essential for designing interventions to prevent the further spread of VRE.

Psoas abscess and cellulitis of the right gluteal region resulting from carcinoma of the cecum

Although retroperitoneal or psoas abscess is an unusual clinical problem, the insidious and occult characteristics of this abscess sometimes cause diagnostic delays, resulting in considerably high morbidity and mortality. In particular, psoas abscess caused by perforated colon carcinoma is uncommon. We report a case of psoas abscess caused by a carcinoma of the cecum. A 72-year-old Japanese woman was admitted to our hospital, with pain in the right groin and buttock. The pain had appeared 6 months before admission, and the symptoms had then been relieved by oral antibiotics. On March 25, 1999, inflammatory signs in the right buttock indicated localized cellulitis, and incision and drainage was performed at a local hospital. The patient was referred to our hospital on the same day. On admission to our hospital, computed tomography (CT) scan revealed a thick right-sided colonic wall and enlargement of the right ileopsoas muscle. Barium enema and colonofiberscopy revealed an ulcerated tumor occupying the entire circumference of the cecum. A retroperitoneal abscess and fistula had been formed by the retroperitoneal perforation of cecum carcinoma: surgical resection was performed after remission of the local inflammatory signs. Operative findings indicated that the cancerous lesion and its surrounding tissues were firmly attached to the right iliopsoas and major psoas muscle, and en-bloc resection, including adjacent muscular tissue, was performed. The fact that carcinoma of the colon could be a cause of psoas abscess and cellulitis in the gluteal region should be considered when an unexplained psoas abscess is diagnosed.