Ultrasound assessment is useful for evaluating balloon volume of resuscitative endovascular balloon occlusion of the aorta

BACKGROUND

Endovascular balloon occlusion of the aorta (EBOA) increases proximal arterial pressure but may also induce life-threatening ischemic complications. Although partial REBOA (P-REBOA) mitigates distal ischemia, it requires invasive monitoring of femoral artery pressure for titration. In this study, we aimed to titrate P-REBOA to prevent high-degree P-REBOA using ultrasound assessment of femoral arterial flow.

METHODS

Proximal (carotid) and distal (femoral) arterial pressures were recorded, and perfusion velocity of distal arterial pressures was measured by pulse wave Doppler. Systolic and diastolic peak velocities were measured among all ten pigs. Total REBOA was defined as a cessation of distal pulse pressure, and maximum balloon volume was documented. The balloon volume (BV) was titrated at 20% increments of maximum capacity to adjust the degree of P-REBOA. The distal/proximal arterial pressure gradient and the perfusion velocity of distal arterial pressures were recorded.

RESULTS

Proximal blood pressure increased with increasing BV. Distal pressure decreased with increasing BV, and distal pressure sharply decreased by > 80% of BV. Both systolic and diastolic velocities of the distal arterial pressure decreased with increasing BV. Diastolic velocity could not be recorded when the BV of REBOA was > 80%.

CONCLUSION

The diastolic peak velocity in the femoral artery disappeared when %BV was > 80%. Evaluation of the femoral artery pressure by pulse wave Doppler may predict the degree of P-REBOA without invasive arterial monitoring.

High versus low positive end-expiratory pressure setting in patients receiving veno-venous extracorporeal membrane oxygenation support for severe acute respiratory distress syndrome: study protocol for the multicentre, randomised ExPress SAVER Trial

INTRODUCTION

While limiting the tidal volume to 6 mL/kg during veno-venous extracorporeal membrane oxygenation (V-V ECMO) to ameliorate lung injury in patients with acute respiratory distress syndrome (ARDS) is widely accepted, the best setting for positive end-expiratory pressure (PEEP) is still controversial. This study is being conducted to investigate whether a higher PEEP setting (15 cmH2O) during V-V ECMO can decrease the duration of ECMO support needed in patients with severe ARDS, as compared with a lower PEEP setting.

METHODS AND ANALYSIS

The study is an investigator-initiated, multicentre, open-label, two-arm, randomised controlled trial conducted with the participation of 20 intensive care units (ICUs) at academic as well as non-academic hospitals in Japan. The subjects of the study are patients with severe ARDS who require V-V ECMO support. Eligible patients will be randomised equally to the high PEEP group or low PEEP group. Recruitment to the study will continue until a total of 210 patients with ARDS requiring V-V ECMO support have been randomised. In the high PEEP group, PEEP will be set at 15 cmH2O from the start of V-V ECMO until the trials for liberation from V-V ECMO (or until day 28 after the allocation), while in the low PEEP group, the PEEP will be set at 5 cmH2O. Other treatments will be the same in the two groups. The primary endpoint of the study is the number of ECMO-free days until day 28, defined as the length of time (in days) from successful libration from V-V ECMO to day 28. The secondary endpoints are mortality on day 28, in-hospital mortality on day 60, ventilator-free days during the first 60 days and length of ICU stay.

ETHICS AND DISSEMINATION

Ethics approval for the trial at all the participating hospitals was obtained on 27 September 2022, by central ethics approval (IRB at Hiroshima University Hospital, C2022-0006). The results of this study will be presented at domestic and international medical congresses, and also published in scientific journals.

TRIAL REGISTRATION NUMBER

The Japan Registry of Clinical Trials jRCT1062220062. Registered on 28 September 2022.

PROTOCOL VERSION

28 March 2023, version 4.0.

The Restrictive Red Blood Cell Transfusion Strategy for Critically Injured Patients (RESTRIC) trial: a cluster-randomized, crossover, non-inferiority multicenter trial of restrictive transfusion in trauma

BACKGROUND

The efficacies of fresh frozen plasma and coagulation factor transfusion have been widely evaluated in trauma-induced coagulopathy management during the acute post-injury phase. However, the efficacy of red blood cell transfusion has not been adequately investigated in patients with severe trauma, and the optimal hemoglobin target level during the acute post-injury and resuscitation phases remains unclear. Therefore, this study aimed to examine whether a restrictive transfusion strategy was clinically non-inferior to a liberal transfusion strategy during the acute post-injury phase.

METHODS

This cluster-randomized, crossover, non-inferiority multicenter trial was conducted at 22 tertiary emergency medical institutions in Japan and included adult patients with severe trauma at risk of major bleeding. The institutions were allocated a restrictive or liberal transfusion strategy (target hemoglobin levels: 7-9 or 10-12 g/dL, respectively). The strategies were applied to patients immediately after arrival at the emergency department. The primary outcome was 28-day survival after arrival at the emergency department. Secondary outcomes included transfusion volume, complication rates, and event-free days. The non-inferiority margin was set at 3%.

RESULTS

The 28-day survival rates of patients in the restrictive (n = 216) and liberal (n = 195) strategy groups were 92.1% and 91.3%, respectively. The adjusted odds ratio for 28-day survival in the restrictive versus liberal strategy group was 1.02 (95% confidence interval: 0.49-2.13). Significant non-inferiority was not observed. Transfusion volumes and hemoglobin levels were lower in the restrictive strategy group than in the liberal strategy group. No between-group differences were noted in complication rates or event-free days.

CONCLUSIONS

Although non-inferiority of the restrictive versus liberal transfusion strategy for 28-day survival was not statistically significant, the mortality and complication rates were similar between the groups. The restrictive transfusion strategy results in a lower transfusion volume.

TRIAL REGISTRATION NUMBER

umin.ac.jp/ctr: UMIN000034405, registration date: 8 October 2018.

Contact-free assessments of respiratory rate and volume with load cells under the bed legs in ventilated patients: A prospective exploratory observational study

Development of reliable non-contact unrestrained respiratory monitoring is capable of augmenting the safety of hospitalized patients in the recovery phase. We previously discovered respiratory-related centroid shifts along the long axis of the bed with load cells under the bed legs (bed sensor system: BSS). This prospective exploratory observational study examined whether non-contact measurements of respiratory-related tidal centroid shift amplitude (TA-BSS: primary variable) and respiratory rate (RR-BSS: secondary variable) were correlated with tidal volume (TV-PN) and respiratory rate (RR-PN), respectively measured by pneumotachograph in 14 ICU patients under mechanical ventilation. Among the 10-minute average data automatically obtained for a 48-hour period, 14 data were randomly selected from each patient. Successfully and evenly selected 196 data points for each variable were used for the purpose of this study. A good agreement between TA-BSS and TV-PN (Pearson's r = 0.669) and an excellent agreement between RR-BSS and RR-PN (r = 0.982) were observed. Estimated minute ventilatory volume as 3.86*TA-BSS*RR-BSS (MV-BSS) was found to be in very good agreement with true minute volume (MV-PN) (r = 0.836). Although Bland-Altman analysis evidenced accuracy of MV-BSS by a small insignificant fixed bias (-0.02 liter/min), a significant proportional bias of MV-BSS (r = -0.664) appeared to produce larger precision (1.9 liter/min) of MV-BSS. We conclude that contact-free unconstraint respiratory monitoring with load cells under the bed legs may serve as a new clinical monitoring system, when improved.

Fatal case of Capnocytophaga sepsis from a dog bite in a patient with splenic hypoplasia

Background

Capnocytophaga canimorsus is an oral commensal bacteria in dogs and may cause severe infection following a dog bite. This is a case of fatal C. canimorsus sepsis with acute infectious purpura fulminans (AIPF) in a healthy patient with splenic hypoplasia.

Case Presentation

A healthy 49-year-old man was admitted to the intensive care unit (ICU) for septic shock and AIPF 4 days after a dog bite to his mouth. Computed tomography revealed a small spleen measuring 53 cm³ but no other source of infection. Despite intensive care, the patient died of multiple organ failure and progressive shock on the fifth ICU day. Polymerase chain reaction of blood samples identified the C. canimorsus gene on a later day.

Conclusion

Capnocytophaga canimorsus from dog bites may cause fatal AIPF. Splenic hypoplasia and bite wounds in well-perfused areas such as the oral cavity are possible risk factors for sepsis. All dog bites should warrant medical attention.

Uterine rupture successfully treated with a damage-control strategy of hysterectomy and resuscitative endovascular balloon occlusion of the aorta-assisted cardiopulmonary resuscitation

Background

Uterine rupture is a major cause of postpartum hemorrhage (PPH) that requires surgery. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is also helpful for PPH. However, the effectiveness of REBOA in PPH with cardiac arrest is unknown.

Case Presentation

A 40-year-old woman developed hemorrhagic shock due to uterine rupture after an induced delivery. She developed cardiac arrest, but was rescued by cardiopulmonary resuscitation (CPR), REBOA, a hysterectomy, and pelvic gauze packing. The hemodynamics were too unstable to move to the operating room. Then we initiated the CPR assisted with REBOA and decided to activate massive transfusion and perform laparotomy in the emergency room. She was finally discharged home without neurological sequelae.

Conclusion

Our damage control strategy, including REBOA-assisted CPR, contributed to saving the life of a patient with a life-threatening PPH.

Esophageal perforation and septic shock after accidental coin ingestion in elderly person

An 88-year-old man ingested coins accidentally and developed mediastinitis and septic shock. Esophageal injuries by sharped-shape foreign bodies are often reported, but esophageal perforation by round coins is rare. Even rounded-shape foreign bodies that are unlikely to injure esophagus may lead to severe outcomes.

Fluid restriction management in the treatment of COVID-19: a single-center observational study

The relationship between fluid management and the severity of illness, duration of treatment, and outcome of coronavirus disease 2019 (COVID-19) is not fully understood. This study aimed to evaluate whether weight change during hospitalization was associated with COVID-19 severity, length of hospital stay, and route of admission. In this study, we assessed the effectiveness of fluid restriction management in patients with severe COVID-19. COVID-19 patients admitted to our hospital between July 2020 and October 2021 were analyzed. Patients were treated with standard drug therapy based on the Japanese guidelines and respiratory support according to the severity of the disease. Early enteral nutrition, defecation management, and anticoagulation therapy were also administered. Fluid restriction management was performed using furosemide and continuous renal replacement therapy as needed unless hemodynamic instability or hyperlactatemia was present. Patient background, route of admission (ambulance, A; transfer, T), weight at admission and discharge, the severity of illness (oxygen therapy, G1; mechanical ventilation, G2; extracorporeal membrane oxygenation, G3), in-hospital mortality, and length of hospital stay were analyzed. There were 116 subjects: G1 (n = 48), G2 (n = 43), and G3 (n = 25), with ages (median [IQR]) of 58 (47-70), 65 (53-71.5), 56 (51-62) years, 40 (83.3%), 31 (72.1%), and 19 (76.0%) males, respectively. Hospital stays were 4.5 (2-7), 10 (7-16), and 18 (15-26) days, and the in-hospital mortality rates were 0 (0%), 7 (16.3%), and 8 (32%), respectively. Body mass index on admission was 26 (23.1-30.2), 27.1 (22.7-31.1), and 31.5 (27.1-33.1) kg/m2, and weight loss during admission was 1.1 (0-2.9), 4.6 (2.3-5.7), 9.2 (5.6-10.5) kg (P < 0.001, Jonckheere-Terpstra test. Weight loss in the severe group (G2 + G3) was 3.4 (0.5-5.8) kg [A, n = 12] and 5.6 (4.4-9) kg [T, n = 43] [P = 0.026, Mann-Whitney U test]. The lengths of hospital stay were 5 (2-7), 9 (7-15), and 18 (12-26) days [P < 0.001, Jonckheere-Terpstra test]. In our fluid restriction management, patients with severe COVID-19 had significant longer hospital length of stay, weight loss, especially those who were transferred to the hospital.

Resuscitative Endovascular Balloon Occlusion of the Aorta Complications and its Management

Numerous complications have been reported regarding the use of resuscitative endovascular balloon occlusion of the aorta (REBOA). Complications can be broadly classified into the following six categories: arterial access-related, REBOA catheter insertion-related, balloon positioning-related, balloon inflation-related, balloon deflation-related, sheath placement, and removal-related. REBOA operators must be knowledgeable about these possible complications and their management, along with its utility. A strong commitment to using REBOA safely and complication-free is essential to the skillful use of REBOA.

Techniques for Performing Resuscitative Endovascular Balloon Occlusion of the Aorta

Although resuscitative endovascular balloon occlusion of the aorta (REBOA) is a useful technique for achieving temporary hemostasis until radical hemostasis is achieved, it is necessary to understand and learn its correct use to avoid complications. The procedure of REBOA preparation, insertion, balloon inflation and deflation, and removal and the key points of the technique at each stage are described in this article. In addition, it expounds on the complications of REBOA and REBOA-inflation time.

Proactive Use of Whole Body Computed Tomography and Resuscitative Endovascular Balloon Occlusion of the Aorta in Hemodynamically Unstable Trauma Patients

It has been well known that the whole body computed tomography (WBCT) scan in hemodynamically unstable trauma patients should not be performed due to the time concern. Recently, with the shortening of the CT scan time accomplished by its quick preparation and scanning, WBCT in those patient population including resuscitative endovascular balloon occlusion of the aorta (REBOA) utilization could lead to better subsequent management, especially to patients with certain situations. At the time of CT scan with contrast, REBOA is not necessarily deflated further. The training of CT scanning could shorten the CT room stay time even within 5 min. The images acquired should be read quickly and precisely following focused assessment with CT for trauma by a trauma radiologist. REBOA-WBCT scan in hemodynamically unstable trauma patients with appropriate protocols and image readings might be the tool for choosing a better modality in order for us to restrain hemorrhage.

Present Strategy for REBOA Management After Catheter Placement: A Current Suggestion From the Japanese Society of DIRECT

Although there is insufficient evidence of the target blood pressure under the utilization of Resuscitative endovascular balloon occlusion of the aorta (REBOA), it may be reasonable to extend the concept of permissive hypotension, which is adapted for hemorrhagic shock, to REBOA management. Invasive blood pressure monitoring proximal to the aortic occlusion is desirable during REBOA. The zone of the aorta is selected and changed according to the location of injuries and physiological conditions. The key to successful REBOA management is to set up an independent REBOA coordinator for systemic management. This review article aims to explain the proper REBOA management to fill the knowledge gap between the educational course, which highlights the indication and safe procedures of the device, and the critical settings faced in the clinical practices.

Resuscitative Thoracotomy and Aortic Cross-Clamp and Resuscitative Endovascular Balloon Occlusion of the Aorta

There are three methods of aortic occlusion; RTACC (resuscitative thoracotomy with aortic cross-clamp), abdominal aortic compression/occlusion after laparotomy, and REBOA. It is essential to understand the characteristics of each methods and use them appropriately according to the situation or in combination. RTACC is characterized by its rapidity and certainty, but highly invasive. Abdominal aortic compression/occlusion is beneficial because hemostasis after laparotomy can be performed simultaneusly. Advantages of REBOA compared to RTACC are minimaly-invasiveness and safety, and disadvantages are rapidity and certainty. However, it is not necessary to discuss the superiority or inferiority of RTACC and REBOA. The appropriate determination of a combination of these tactics will increase the range of strategies. In particular, RTACC should be performed promptly for impending cardiac arrest and early conversion to REBOA can be helpful regarding to prevention of hypothermia and reduction of chest wall bleeding (To "REBOA & RTACC" instead of "REBOA vs RTACC").

Endovascular Strategy in Obstetrics

Postpartum hemorrhage (PPH) requires medical resources to resuscitate hemorrhagic shock patients. The concept of damage control surgery in obstetrics has become widespread, and resuscitative endovascular balloon occlusion of the aorta (REBOA) can be a means of resuscitation in PPH. However, the potential benefits of endovascular strategies in obstetrics are not fully understood. This review discusses surgical and endovascular strategies for perinatal resuscitation and hemostasis. The endovascular strategies include REBOA, arterial embolization, and common or internal iliac artery balloon occlusion (CIABO or IIABO). Uterine artery embolization achieves rapid definitive hemostasis while leaving fertility with a less invasive procedure. N-butyl-2-cyanoacrylat (NBCA) should be chosen as needed for coagulopathy. The obstetrics and resuscitation team would have to develop each command system, and control and cooperate in parallel. The consensus for the timing of arterial access and the patient’s positioning for pelvic examination and femoral arterial access should be established in advance.

A Guide to Femoral Arterial Access for Resuscitative Endovascular Balloon Occlusion of the Aorta

Abstract Arterial access is essential in resuscitation of trauma and hemorrhagic shock patients and can be effectively used for rapid endovascular treatment such as resuscitative endovascular balloon occlusion of the aorta (REBOA) and interventional radiology (IVR), continuous invasive hemodynamic monitoring, and frequent blood tests. In the REBOA procedure, obtaining an arterial access is the first and most critical step. Arterial access can be obtained in three ways: i) blind/landmark technique, ii) ultrasound-guided technique, or iii) surgical cutdown technique. Regardless of which technique is chosen, it is crucial to recognize external landmarks before implementing any technique. 

Indication of Resuscitative Endovascular Balloon Occlusion of the Aorta in Trauma Patients

In trauma bays, resuscitation as a bridge to definitive hemorrhage control to avoid cardiac arrest is challenging. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a resuscitation procedure for refractory hemorrhagic shock. The REBOA procedure itself is simple compared to other endovascular procedures, such as angioembolization or stent graft placement. However, adequate REBOA implementation requires a complete understanding of its potential risks and simulation training. We should be aware that REBOA is not a hemostatic device, but a bridge to definitive hemorrhage control; furthermore, it is not a magical device that can improve the critical situation in trauma resuscitation. For appropriate use, we herein describe the indication of REBOA in trauma resuscitation based on existing evidence.

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.

Partial Resuscitative Endovascular Balloon Occlusion of the Aorta and Intermittent Resuscitative Endovascular Balloon Occlusion of the Aorta

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a resuscitation procedure for severe hemorrhagic shock. While complete occlusion of the aorta could be effective for the control of blood flow, there is always a concern for ischemia-reperfusion injury of the distal organs from the balloon catheter. REBOA can control the degree of occlusion by changing the injection volume of the balloon catheter. Partial REBOA and intermittent REBOA are some of the strategies of REBOA, with which less ischemia-perfusion injury is done, rather than complete occlusion of the aorta, although evidence on partial REBOA and intermittent REBOA is still limited.

Prevalence of and risk factors for depressive symptoms in non-tuberculous mycobacterial pulmonary disease

BACKGROUND: The presence of depressive symptoms in patients with non-tuberculous mycobacterial pulmonary disease (NTM-PD) is an important research topic; however, the prevalence of depressive symptoms and the factors that influence their development are unclear.OBJECTIVE: To analyse the association between CES-D (Center for Epidemiological Studies Depression Scale) scores and clinical parameters such as age, disease duration, pulmonary function, imaging findings, blood data, physical functions, sleep disturbances, respiratory symptoms and health-related quality of life (HRQOL).METHODS: We conducted a cross-sectional retrospective study of 114 patients with NTM-PD at a single centre from March 2016 to January 2021 to evaluate the relationship between CES-D scores and clinical parameters.RESULTS: Participants had a median age of 64 years; 32.5% of them had depressive symptoms. Disease duration, albumin, C-reactive protein, pulmonary function, dyspnoea, exercise capacity, respiratory symptoms, cough-related HRQOL and sleep disturbances were associated with depressive symptoms. Binomial logistic regression analyses indicated that the CES-D score was significantly associated with cough-related HRQOL and sleep disturbances.CONCLUSION: A high percentage of NTM-PD patients in this study experienced depressive symptoms, and these patients had abnormalities of various clinical parameters. Cough-related HRQOL and sleep disturbance had a strong influence on the development of depressive symptoms.

Minimising the biases in the observational study of resuscitative endovascular balloon occlusion of the aorta: a research protocol for a prospective study analysed with propensity score matching with time-varying covariates

INTRODUCTION

Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been used as a bridge to definitive bleeding control of subdiaphragmatic injury. Since previous observational studies have poorly adjusted for confounding factors, it is necessary to incorporate REBOA-specific and time-varying covariates in the model. We hypothesised that REBOA improves the survival of haemodynamically unstable torso trauma patients after comparing the REBOA group with a matched control group (non-REBOA group).

METHODS AND ANALYSIS

The Japanese Association for the Surgery of Trauma-REBOA Study is a prospective, multicentre, matched cohort study organised by the Clinical Trial Committee of the Japanese Association for the Surgery of Trauma. To minimise observational study biases, this study will prospectively register traumatic shock patients who require bleeding control within 60 min upon arrival at the emergency department, with in-hospital mortality as the primary outcome. After the data set is fixed, the missing values for all variables will be imputed using the multiple imputation technique. In the primary analysis, propensity scores for the probability of REBOA decision (regardless of the actual REBOA deployment) will be calculated from the baseline information using a logistic regression generalised linear mixed-effects model, which will be performed for both the REBOA use and non-REBOA use groups.

ETHICS AND DISSEMINATION

This study was approved by the ethics committee of each participating hospital. The results will be disseminated to the participating hospitals, submitted to peer-reviewed journals for publication and presented at congresses.

TRIAL REGISTRATION NUMBER

UMIN Clinical Trials Registry (UMIN000035458).

Successful application of angioembolization and thoracic endovascular aortic repair (TEVAR) in a retrograde type-A acute aortic dissection with polytrauma

A 53-year-old man underwent thoracic endovascular aortic repair for persistent false lumen perfusion and limb salvage because of type A aortic dissection, severe lower-limb ischemia, and bleeding (mediastinal hematoma, bilateral lung contusion, liver injury, and splenic injury) caused by blunt trauma. We embolized the left supreme intercostal artery to control active mediastinal hemorrhage. Acute hemorrhage and leg ischemia were well controlled; however, residual blood flow in the false lumen persisted. We performed a Zone 2 thoracic endovascular aortic repair and discharged the patient on day 67. Thoracic endovascular aortic repair is a practical option for treating traumatic type A dissection.

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.

Mid-term clinical outcomes and complications of primary total knee arthroplasty in hemodialysis patients: a retrospective comparative cohort study

Background

Numerous patients who receive hemodialysis (HD) undergo total knee arthroplasty (TKA) due to advanced knee joint arthritis. However, there are few studies that describe the clinical outcomes and complications of TKA in HD patients. This study investigated the mid-term results of TKA in patients undergoing HD.

Methods

This single-center retrospective study compared clinical and surgical outcomes following TKA in patients who were receiving HD with those who were not. We used propensity scores to match 21 knees of 18 patients who received HD to 706 knees of 569 patients who had not received HD, from a total of 727 knees (587 patients) that underwent primary unilateral TKA. The clinical outcomes were evaluated using the American Knee Society Score-knee (AKSS-knee) and AKSS-function scores. The primary surgical outcome measure was the number of knees with postoperative complications.

Results

In both the HD and non-HD groups, postoperative AKSS-knee and function scores significantly improved when compared to preoperative values. Postoperative AKSS-knee and function scores were not significantly different between the groups. The number of knees with postoperative complications was larger in the HD group than the non-HD group within the first postoperative month, 0–12 months, 12–24 months, 0–24 months, and two years after surgery. Additionally, in the HD group, more complications occurred in the first month than any subsequent month in the two years after surgery.

Conclusions

TKA improves AKSS-knee and function scores equivalently for HD patients and non-HD patients. However, HD patients develop more complications after TKA, especially within the first month. Therefore, surgeons who perform TKA for HD patients should obtain informed consent after explaining the possible complications, and HD patients should be carefully observed following TKA.

Long-term prognostic factors of coronary artery disease patients after out-of-hospital cardiac arrest

Background

The long-term prognosis of survival in patients with out-of-hospital cardiac arrest (OHCA) with coronary artery disease (CAD) remains poor.

Methods

There were 2391 out-of-hospital cardiac arrest (OHCA) patients transferred to 2 hospitals. We included 405 cardiovascular arrest patients, who got return of spontaneous circulation (ROSC) from January 2015 to December 2018. Among them, 204 patients had CAD that caused OHCA (39%: multi-vessel disease, 19%: chronic total occlusion (CTO), 13%: vasospastic angina (VSA)). To predict mortality, we investigated patients' characteristics, pre-hospital information and findings of CAG.

Results

At 1-year later, 104 patients (51%) survived. Younger age (P&lt;0.001), VF survivor (P&lt;0.001), pre-hospital ROSC (P&lt;0.001), bystander CPR (P=0.013), without ECMO (P&lt;0.001), lower lactate level on admission (P&lt;0.001), and higher geriatric nutritional risk index score (P&lt;0.001) were associated with low 1-year mortality, while with ST-segment elevation (P=0.778), BMI level (P=0.344), and sex (0.401) were not. And in the findings of CAG, the past history of CAD (P=0.049), the higher number of coronary vessel disease (P=0.003) such as multi-vessel disease (P=0.022), higher SYNAX score (P=0.016), and larger infarct size (max CK level; P=0.013, max CK-MB level; P&lt;0.001) were associated with high 1-year mortality. On the other hand, acute coronary syndrome (P=0.300), any coronary lesion (RCA (P=0.447), LAD (P=0.089), LCX (P=0.096), or LMT (P=0.842)), and with CTO lesion (P=0.140) were not associated. Zero-vessel disease (VSA, P=0.001) had lower mortality among the CAD patients. In the multivariate Cox proportional hazards model, age (hazards ratio; HR: 1.03, 95%confidence interval (CI) 1.00–1.06, P&lt;0.001) and bystander CPR (HR: 0.36, 95% CI 0.20–0.65, P&lt;0.001) were the independent predictors of mortality.

Conclusions

Younger age and pre-hospital support after OHCA with CAD were the predictors of low mortality. Pre-hospital information, systemic condition on arrival, or anatomical coronary complexity were important to predict low mortality.

Funding Acknowledgement

Type of funding sources: None.

Neurological outcome at 30-day as an estimator of 1-year functional status after out-of-hospital cardiac arrest with post-encephalopathy

Background

Implantation of implantable cardioverter-defibrillators (ICD) for secondary prevention is fully recommended for those with an estimated survival over 1-year with a good functional status. However, we often face the difficulty to estimate the functional status and hesitate to implant ICD for patients with post-resuscitation encephalopathy.

Methods

There were 2391 out-of-hospital cardiac arrest (OHCA) patients transferred to 2 hospitals. We included 405 cardiovascular arrest patients, who got return of spontaneous circulation (ROSC) from January 2015 to December 2018. Among the patients, 343 patients could be considered to be implanted ICD for secondary prevention according to the initial waveform or the causes of OHCA. At 1-month later, 184 patients (54%) survived. To assess the association of functional status at 30-day and 1-year, we investigated patients' characteristics, pre-hospital information and clinical findings, and evaluated the neurological outcome according to the cerebral performance category (CPC) scale.

Results

At 1-month later, 145 patients (79%) survived with CPC≤2, and 39 patients (21%) survived with CPC&gt;2. Bystander CPR (P=0.009), pre-hospital ROSC (P&lt;0.001), low lactate level on admission (P=0.001), high geriatric nutritional risk index score (P&lt;0.001) and without ECMO (P=0.002) were significantly associated with good neurological outcome at 30-day. The 1-year Kaplan-Meier event rate revealed significantly different survival rate (CPC&gt;2 at 30-day:38.5%, vs CPC≤2 at 30-day:97.2%; P&lt;0.001). In multivariate analysis, CPC scale at 30-day (OR 0.022; 95% CI 0.003–0.140; p&lt;0.001) was the independent predictor of favorable neurological outcome at 1-year. Among the patients with CPC&gt;2 at 30-day, only 3 patients (7.7%) of CPC=3 achieved the improvement of neurological outcome at 1-year (CPC≤2), while no patient of CPC=4 did. And one patient (2.5%) with CPC=3 was implanted ICD during the follow-up period. Twenty-five patients (64%) died of non-cardiovascular death with frailty of post-resuscitation encephalopathy after they were transferred to other hospital with the acceptation and intention of the do-not-attempt-resuscitation.

Conclusions

Neurological prognosis at 30-day after OHCA might be an estimator of 1-year functional status to guide us to implant ICD for secondary prevention.

Funding Acknowledgement

Type of funding sources: None.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020)

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members.As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.

Health-related quality of life associates with clinical parameters in patients with NTM pulmonary disease

BACKGROUND: Previous studies have shown a reduction in health-related quality of life (HRQoL) in patients with non-tuberculous mycobacterial pulmonary disease (NTM-PD). However, the causes of this decline and the factors that contribute to it are unknown. This study was conducted to analyse the association between the St George´s Respiratory Questionnaire (SGRQ) and clinical parameters, including age, disease duration, body composition, pulmonary function, chest X-ray findings, blood data and physical function.METHODS: We performed a single-centre, cross-sectional, retrospective study of 101 patients with NTM-PD from December 2016 to October 2019. The relationship between the SGRQ scores and clinical parameters was evaluated.RESULTS: The median patient age was 67.0 years. Pulmonary function, radiological score, albumin levels, C-reactive protein levels and incremental shuttle walk test distance (ISWD) were significantly correlated with the total and component scores on the SGRQ. Multiple regression analysis showed that the SGRQ score was significantly associated with radiological score, pulmonary function and ISWD.CONCLUSION: This study was the first to assess the effect of clinical parameters on the SGRQ in patients with NTM-PD. HRQoL as determined using the SGRQ was associated with the radiological score, pulmonary function and ISWD in patients with NTM-PD.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020)

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members. As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.

Clinical course of a critically ill patient with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)

Although several studies have reported on the clinical and epidemiological characteristics of the patient with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), clinical course of the most severe cases requiring treatment in ICU have been insufficiently reported. A 73-year-old man traveling on a cruise ship with history of hypertension and dyslipidemia developed high fever, dyspnea and cough after 7 days of steroid treatment for sudden sensorineural hearing loss, and tested positive for SARS-CoV-2 in sputa polymerase chain reaction (PCR) examination. His respiratory function deteriorated despite treatments with lopinavir/ritonavir, oseltamivir, azithromycin and meropenem at a regional hospital. He was intubated and transferred to the ICU in the tertiary university hospital on day 10 (ICU day 1). Interferon beta-1b subcutaneous injection was initiated immediately to enhance anti-viral therapy, and favipiravir on ICU day 10 upon availability. Progression of organ dysfunctions necessitated inhalation of nitrogen oxide for respiratory dysfunction, noradrenaline for cardiovascular dysfunction and continuous renal replacement therapy for renal dysfunction. His blood samples PCR also tested positive for SARS-CoV-2, indicating viremia, concomitantly with elevated IL-6 levels. VV-ECMO was initiated after sudden exacerbation of respiratory dysfunction on ICU day 7 to maintain oxygenation. The sustained excessive inflammatory cytokines in the present case might have led to the exacerbation of the disease, requiring vigorous organ support therapies to allow for survival and recovery from the rapid progression of multiple organ dysfunctions and severe respiratory failure.

Restrictive transfusion strategy for critically injured patients (RESTRIC) trial: a study protocol for a cluster-randomised, crossover non-inferiority trial

INTRODUCTION

Resuscitation using blood products is critical during the acute postinjury period. However, the optimal target haemoglobin (Hb) levels have not been adequately investigated. With the restrictive transfusion strategy for critically injured patients (RESTRIC) trial, we aim to compare the restrictive and liberal red blood cell (RBC) transfusion strategies.

METHODS AND ANALYSIS

This is a cluster-randomised, crossover, non-inferiority trial of patients with severe trauma at 22 hospitals that have been randomised in a 1:1 ratio based on the use of a restrictive or liberal transfusion strategy with target Hb levels of 70-90 or 100-120 g/L, respectively, during the first year. Subsequently, after 1-month washout period, another transfusion strategy will be applied for an additional year. RBC transfusion requirements are usually unclear on arrival at the emergency department. Therefore, patients with severe bleeding, which could lead to haemorrhagic shock, will be included in the trial based on the attending physician's judgement. Each RBC transfusion strategy will be applied until 7 days postadmission to the hospital or discharge from the intensive care unit. The outcomes measured will include the 28-day survival rate after arrival at the emergency department (primary), the cumulative amount of blood transfused, event-free days and frequency of transfusion-associated lung injury and organ failure (secondary). Demonstration of the non-inferiority of restrictive transfusion will emphasise its clinical advantages.

ETHICS AND DISSEMINATION

The trial will be performed according to the Japanese and International Ethical guidelines. It has been approved by the Ethics Committee of each participating hospital and The Japanese Association for the Surgery of Trauma (JAST). Written informed consent will be obtained from all patients or their representatives. The results of the trial will be disseminated to the participating hospitals and board-certified educational institutions of JAST, submitted to peer-reviewed journals for publication, and presented at congresses.

TRIAL REGISTRATION NUMBER

UMIN Clinical Trials Registry; UMIN000034405. Registered 8 October 2018.

Material stiffness variation in mosquito antennae

The antennae of mosquitoes are model systems for acoustic sensation, in that they obey general principles for sound detection, using both active feedback mechanisms and passive structural adaptations. However, the biomechanical aspect of the antennal structure is much less understood than the mechano-electrical transduction. Using confocal laser scanning microscopy, we measured the fluorescent properties of the antennae of two species of mosquito—Toxorhynchites brevipalpis and Anopheles arabiensis—and, noting that fluorescence is correlated with material stiffness, we found that the structure of the antenna is not a simple beam of homogeneous material, but is in fact a rather more complex structure with spatially distributed discrete changes in material properties. These present as bands or rings of different material in each subunit of the antenna, which repeat along its length. While these structures may simply be required for structural robustness of the antennae, we found that in FEM simulation, these banded structures can strongly affect the resonant frequencies of cantilever-beam systems, and therefore taken together our results suggest that modulating the material properties along the length of the antenna could constitute an additional mechanism for resonant tuning in these species.

The off-hour effect among severe trauma patients: a nationwide cohort study in Japan

PURPOSE

To assess whether there are temporal differences altering the clinical outcomes of severe trauma patients in Japan.

METHODS

This was a retrospective cohort study that used recorded data from the Japan Trauma Data Bank. Severe trauma patients who had an injury severity score of greater than 16 were included. The hospital arrival time was categorized into daytime (8 a.m.-7:59 p.m.) and nighttime (8 p.m.-7:59 a.m.). The hospital arrival day of the week was categorized into business days and non-business days. The primary outcome was in-hospital mortality.

RESULTS

A total of 65,136 severe trauma patients were analyzed. In-hospital mortality was 15.6% in the daytime and 14.4% in the nighttime, and 15.5%, and 14.6% on business days and non-business days, respectively. Nighttime was associated with decreased in-hospital mortality compared to daytime (odds ratio = 0.817, 95% confidence interval = 0.764-0.874) and a non-business day was not associated with in-hospital mortality.

CONCLUSIONS

We did not find a negative off-hour effect on in-hospital mortality among severe trauma patients.

Search for η^{'} Bound Nuclei in the ^{12}C(γ,p) Reaction with Simultaneous Detection of Decay Products

We measured missing mass spectrum of the ^{12}C(γ,p) reaction for the first time in coincidence with potential decay products from η^{'} bound nuclei. We tagged an (η+p) pair associated with the η^{'}N→ηN process in a nucleus. After applying kinematical selections to reduce backgrounds, no signal events were observed in the bound-state region. An upper limit of the signal cross section in the opening angle cosθ_{lab}^{ηp}<-0.9 was obtained to be 2.2  nb/sr at the 90% confidence level. It is compared with theoretical cross sections, whose normalization ambiguity is suppressed by measuring a quasifree η^{'} production rate. Our results indicate a small branching fraction of the η^{'}N→ηN process and/or a shallow η^{'}-nucleus potential.

Organ ischemia during partial resuscitative endovascular balloon occlusion of the aorta: Dynamic 4D Computed tomography in swine

Resuscitative endovascular balloon occlusion of the aorta (REBOA) increases proximal pressure, and simultaneously induces distal ischemia. We aimed to evaluate organ ischemia during partial REBOA (P-REBOA) with computed tomography (CT) perfusion in a swine model. The maximum balloon volume was recorded as total REBOA when the distal pulse pressure ceased. The animals (n = 4) were scanned at each 20% of the maximum balloon volume, and time-density curve (TDC) were analysed at the aorta, portal vein (PV), liver parenchyma, and superior mesenteric vein (SMV, indicating mesenteric perfusion). The area under the TDC (AUTDC), the time to peak (TTP), and four-dimensional volume-rendering images (4D-VR) were evaluated. The TDC of the both upper and lower aorta showed an increased peak and delayed TTP. The TDC of the PV, liver, and SMV showed a decreased peak and delayed TTP. The dynamic 4D-CT analysis suggested that organ perfusion changes according to balloon volume. The AUTDC at the PV, liver, and SMV decreased linearly with balloon inflation percentage to the maximum volume. 4D-VR demonstrated the delay of the washout in the aorta and retrograde flow at the inferior vena cava in the highly occluded status.

Aortic balloon occlusion (REBOA) in pelvic ring injuries: preliminary results of the ABO Trauma Registry

EndoVascular and Hybrid Trauma Management (EVTM) has been recently introduced in the treatment of severe pelvic ring injuries. This multimodal method of hemorrhage management counts on several strategies such as the REBOA (resuscitative endovascular balloon occlusion of the aorta). Few data exist on the use of REBOA in patients with a severely injured pelvic ring. The ABO (aortic balloon occlusion) Trauma Registry is designed to capture data for all trauma patients in hemorrhagic shock where management includes REBOA placement. Among all patients included in the ABO registry, 72 patients presented with severe pelvic injuries and were the population under exam. 66.7% were male. Mean and median ISS were respectively 43 and 41 (SD ± 13). Isolated pelvic injuries were observed in 12 patients (16.7%). Blunt trauma occurred in 68 patients (94.4%), penetrating in 2 (2.8%) and combined in 2 (2.8%). Type of injury: fall from height in 15 patients (23.1%), traffic accident in 49 patients (75.4%), and unspecified impact in 1 patient (1.5%). Femoral access was gained pre-hospital in 1 patient, in emergency room in 43, in operating room in 12 and in angio-suite in 16. REBOA was positioned in zone 1 in 59 patients (81,9%), in zone 2 in 1 (1,4%) and in zone 3 in 12 (16,7%). Aortic occlusion was partial/periodical in 35 patients (48,6%) and total occlusion in 37 patients (51,4%). REBOA associated morbidity rate: 11.1%. Overall mortality rate was 54.2% and early mortality rate (≤ 24 h) was 44.4%. In the univariate analysis, factors related to early mortality (≤ 24 h) are lower pH values (p = 0.03), higher base deficit (p = 0.021), longer INR (p = 0.012), minor increase in systolic blood pressure after the REBOA inflation (p = 0.03) and total aortic occlusion (p = 0.008). None of these values resulted significant in the multivariate analysis. In severe hemodynamically unstable pelvic trauma management, REBOA is a viable option when utilized in experienced centers as a bridge to other treatments; its use might be, however, accompanied with severe-to-lethal complications.

Attenuated relationship between salivary oxytocin levels and attention to social information in adolescents and adults with autism spectrum disorder: a comparative study

BACKGROUND

Previous research studies have assessed the relationship between attention to social information and peripheral (e.g., plasma and salivary) oxytocin (OT) levels in typically developing (TD) children and children with autism spectrum disorder (ASD). A relationship between them was observed in TD children, but not in children with ASD. However, this relationship remains unexamined in other age groups. To clarify whether this lack of association is maintained throughout development in individuals with ASD, we aimed to assess the relationship between salivary OT levels and attention to social information in adolescents and adults with and without ASD.

METHODS

We recruited male adolescents and adults with ASD (n = 17) and TD participants (n = 24). Using the all-in-one eye-tracking system Gazefinder, we measured the percentage fixation time allocated to social information. We also measured the salivary OT levels and Autism Spectrum Quotient (AQ) of participants. Subsequently, we confirmed group differences and conducted a correlation analysis to investigate the relationships between these three measures.

RESULTS

Salivary OT levels did not show any significant difference between the ASD and TD groups and were negatively correlated with the AQ in the whole-group analysis, but not in within-group analysis. Individuals with ASD had significantly lower percentage fixation times than did TD individuals for eye regions in human faces with/without mouth motion, for upright biological motion, and for people regions in the people and geometry movies. The percentage of fixation for geometric shapes in the people and geometry movies was significantly higher in the ASD than in the TD group. In the TD group, salivary OT levels were positively correlated with percentage fixation times for upright biological motion and people and negatively correlated with inverted biological motion and geometry. However, no significant correlations were found in the ASD group.

CONCLUSIONS

Our exploratory results suggest that salivary OT levels in adolescents and adults with ASD are less indicative of attention to social stimuli than they are in TD adolescents and adults. It is suggested that their association is slightly weaker in adolescents and adults with ASD and that this attenuated relationship appears to be maintained throughout development.

Kidney and uro-trauma: WSES-AAST guidelines

Renal and urogenital injuries occur in approximately 10-20% of abdominal trauma in adults and children. Optimal management should take into consideration the anatomic injury, the hemodynamic status, and the associated injuries. The management of urogenital trauma aims to restore homeostasis and normal physiology especially in pediatric patients where non-operative management is considered the gold standard. As with all traumatic conditions, the management of urogenital trauma should be multidisciplinary including urologists, interventional radiologists, and trauma surgeons, as well as emergency and ICU physicians. The aim of this paper is to present the World Society of Emergency Surgery (WSES) and the American Association for the Surgery of Trauma (AAST) kidney and urogenital trauma management guidelines.